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NYS Medicaid DME Services Fee Schedule (effective

7/1/2016)
CODE
A4216
A4217
A4221
A4230
A4231
A4233
A4234
A4235
A4244
A4245
A4246
A4250
A4252
A4253
A4256
A4258
A4259
A4265
A4267
A4268
A4310
A4311
A4314
A4320
A4322
A4326
A4331
A4333
A4334
A4335
A4338
A4344
A4346
A4349
A4351
A4352
A4353
A4354
A4356
A4357
A4358
A4361
A4362
A4363
A4364
A4366
A4367
A4368

DESCRIPTION

FEE

STERILE WATER, SALINE AND/OR DEXTROSE, D


STERILE WATER/SALINE,500 ML
SUPPLIES FOR MAINTENANCE OF DRUG INFUSIO
INFUSION SET FOR EXTERNAL INSULIN PUMP,
INFUSION SET FOR EXTERNAL INSULIN PUMP,
REPLACEMENT BATTERY, ALKALINE (OTHER THA
REPLACEMENT BATTERY, ALKALINE, J CELL, F
REPLACEMENT BATTERY, LITHIUM, FOR USE WI
ALCOHOL OR PEROXIDE, PER PINT
ALCOHOL WIPES, PER BOX
BETADINE OR PHISOHEX SOLUTION, PER PINT
URINE TEST OR REAGENT STRIPS OR TABLETS
BLOOD KETONE TEST OR REAGENT STRIP, EACH
BLOOD GLUCOSE TEST OR REAGENT STRIPS FOR
NORMAL, LOW AND HIGH CALIBRATOR SOLUTION
SPRING-POWERED DEVICE FOR LANCET, EACH
LANCETS, PER BOX OF 100
PARAFFIN, PER POUND
CONTRACEPTIVE SUPPLY, CONDOM, MALE, EACH
CONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EA
INSERTION TRAY WITHOUT DRAINAGE BAG AND
INSERTION TRAY WITHOUT DRAINAGE BAG WITH
INSERTION TRAY WITH DRAINAGE BAG WITH IN
IRRIGATION TRAY WITH BULB OR PISTON SYRI
IRRIGATION SYRINGE, BULB OR PISTON, EACH
MALE EXTERNAL CATHETER WITH INTEGRAL COL
EXTENSION DRAINAGE TUBING, ANY TYPE, ANY
URINARY CATHETER ANCHORING DEVICE, ADHES
URINARY CATHETER ANCHORING DEVICE, LEG S
INCONTINENCE SUPPLY MISC
INDWELLING CATHETER; FOLEY TYPE, TWO-WAY
INDWELLING CATHETER, FOLEY TYPE, TWO-WAY
INDWELLING CATHETER; FOLEY TYPE, THREE W
MALE EXTERNAL CATHETER, WITH OR WITHOUT
INTERMITTENT URINARY CATHETER; STRAIGHT
INTERMITTENT URINARY CATHETER; COUDE (CU
INTERMITTENT URINARY CATHETER, WITH INSE
INSERTION TRAY WITH DRAINAGE BAG BUT WIT
EXTERNAL URETHRAL CLAMP OR COMPRESSION D
BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH
URINARY DRAINAGE BAG, LEG OR ABDOMEN, VI
OSTOMY FACE PLATE, EACH
SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT
OSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY
ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PE
OSTOMY VENT, ANY TYPE, EACH
OSTOMY BELT, EACH
OSTOMY FILTER,ANY TYPE, EACH

Page 1 of 34

0.43
1.58
1.00
15.05
6.27
0.71
3.25
2.34
1.12
1.39
2.96
18.85
4.45
24.37
8.62
12.95
5.40
3.33
0.39
3.50
2.13
5.94
11.73
1.67
1.01
4.82
1.80
2.31
1.36
1.34
6.13
10.92
1.51
0.81
2.58
3.11
7.57
37.98
10.19
4.13
11.99
3.63
1.81
2.19
0.86
7.18
0.27

RENTAL
FEE

BR

CODE
A4369
A4371
A4372
A4373
A4375
A4376
A4377
A4378
A4379
A4380
A4381
A4382
A4383
A4384
A4385
A4387
A4388
A4389
A4390
A4391
A4392
A4393
A4394
A4395
A4396
A4397
A4398
A4399
A4400
A4402
A4404
A4405
A4406
A4407
A4408
A4409
A4410
A4411
A4412
A4413
A4414
A4415
A4416
A4417
A4418
A4419
A4420
A4421

DESCRIPTION
OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUS
OSTOMY SKIN BARRIER,POWDER,PER OZ
OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,
OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTA
OSTOMY POUCH, DRAINABLE, WITH FACEPLATE
OSTOMY POUCH, DRAINABLE, FOR USE ON FACE
OSTOMY POUCH, DRAINABLE, FOR USE ON FACE
OSTOMY POUCH, URINARY, WITH FACEPLATE AT
OSTOMY POUCH, URINARY, WITH FACEPLATE AT
OSTOMY POUCH, URINARY, FOR USE ON FACEPL
OSTOMY POUCH, URINARY, FOR USE ON FACEPL
OSTOMY POUCH, URINARY, FOR USE ON FACEPL
OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EA
OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA
OSTOMY POUCH, CLOSED, WITH BARRIER ATTAC
OSTOMY POUCH, DRAINABLE, WITH EXTENDED W
OSTOMY POUCH, DRAINABLE, WITH BARRIER AT
OSTOMY POUCH, DRAINABLE, WITH EXTENDED W
OSTOMY POUCH, URINARY, WITH EXTENDED WEA
OSTOMY POUCH, URINARY, WITH STANDARD WEA
OSTOMY POUCH, URINARY, WITH EXTENDED WEA
OSTOMY DEODORANT, WITH OR WITHOUT LUBRIC
OSTOMY DEODORANT FOR USE IN OSTOMY POUCH
OSTOMY BELT W/PERISTOMAL HERNIA SUPPORT
IRRIGATION SUPPLY SLEEVE EACH
OSTOMY IRRIGATION SUPPLY; BAG, EACH
OSTOMY IRRIGATION SUPPLY; CONE/CATHETER,
OSTOMY IRRIGATION SET EACH
LUBRICANT, PER OUNCE
OSTOMY RING, EACH
OSTOMY SKIN BARRIER, NON-PECTIN BASED, P
OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,
OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID,
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,
OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA
OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FO
OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FO
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,
OSTOMY POUCH, CLOSED, WITH BARRIER ATTAC
OSTOMY POUCH, CLOSED, WITH BARRIER ATTAC
OSTOMY POUCH, CLOSED; WITHOUT BARRIER AT
OSTOMY POUCH, CLOSED; FOR USE ON BARRIER
OSTOMY POUCH, CLOSED; FOR USE ON BARRIER
OSTOMY SUPPLY; MISCELLANEOUS

FEE
2.04
2.49
4.19
6.58
18.04
47.40
4.50
30.11
15.77
39.16
3.53
3.53
29.57
10.10
5.35
3.23
3.77
6.46
8.41
6.40
8.58
9.48
2.71
0.05
40.40
2.73
1.00
12.86
30.09
0.43
1.62
2.36
4.66
8.69
8.64
4.80
4.80
5.10
2.84
5.77
4.54
4.54
2.61
3.82
1.90
1.77
1.55

RENTAL
FEE

BR

CODE
A4422
A4423
A4424
A4425
A4426
A4427
A4428
A4429
A4430
A4431
A4432
A4433
A4434
A4435
A4450
A4452
A4455
A4456
A4458
A4463
A4481
A4495
A4500
A4510
A4554
A4556
A4557
A4565
A4570
A4575
A4602
A4605
A4614
A4615
A4616
A4618
A4619
A4620
A4623
A4624
A4625
A4626
A4628
A4629
A4630
A4632
A4635
A4636

DESCRIPTION
OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYST
OSTOMY POUCH, CLOSED; FOR USE ON BARRIER
OSTOMY POUCH, DRAINABLE, WITH BARRIER AT
OSTOMY POUCH, DRAINABLE; FOR USE ON BARR
OSTOMY POUCH, DRAINABLE; FOR USE ON BARR
OSTOMY POUCH, DRAINABLE; FOR USE ON BARR
OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BA
OSTOMY POUCH, URINARY, WITH BARRIER ATTACHE
OSTOMY POUCH, URINARY, WITH EXTENDED WEAR B
OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED
OSTOMY POUCH, URINARY; FOR USE ON BARRIER WIT
OSTOMY POUCH, URINARY; FOR USE ON BARRIER WIT
OSTOMY POUCH, URINARY; FOR USE ON BARRIER WIT
OSTOMY POUCH, DRAINABLE, HIGH OUTPUT,
TAPE, NON-WATERPROOF, PER 18 SQUARE INCH
TAPE, WATERPROOF, PER 18 SQUARE INCHES
ADHESIVE REMOVER OR SOLVENT (FOR TAPE, C
ADHESIVE REMOVER, WIPES, ANY TYPE, EACH
ENEMA BAG WITH TUBING, REUSABLE
SURGICAL DRESSING HOLDER, REUSABLE, EACH
TRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE,
SURGICAL STOCKINGS THIGH LENGTH, EACH
SURGICAL STOCKINGS BELOW KNEE LENGTH, EA
SURGICAL STOCKINGS FULL LENGTH, EACH
DISPOSABLE UNDERPADS, ALL SIZES
ELECTRODES, (E.G., APNEA MONITOR), PER P
LEAD WIRES, (E.G., APNEA MONITOR), PER P
SLINGS
SPLINT
TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPO
REPLACEMENT BATTERY FOR EXTERNAL INFUSIO
TRACHEAL SUCTION CATHETER, CLOSED SYSTEM
PEAK EXPIRATORY FLOW RATE METER, HAND HE
CANNULA NASAL
TUBING,(OXYGEN),PER FOOT
BREATHING CIRCUITS
FACE TENT
VARIABLE CONCENTRATION MASK
TRACHEOSTOMY, INNER CANNULA
TRACHEAL SUCTION CATHETER, ANY TYPE OTHE
TRACHEOSTOMY CARE KIT FOR NEW TRACHEOSTO
TRACHEOSTOMY CLEANING BRUSH EA
OROPHARYNGEAL SUCTION CATHETER, EACH
TRACHEOSTOMY CARE KIT FOR ESTABLISHED TR
REPLACEMENT BATTERIES, MEDICALLY NECESSA
REPLACEMENT BATTERY FOR EXTERNAL INFUSIO
UNDERARM PAD,CRUTCH,REPLACEMENT EACH
REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR

FEE
0.13
1.90
3.15
3.52
1.76
2.75
6.84
8.66
8.95
6.53
3.77
3.51
3.95
6.26
0.06
0.11
1.28
0.24
16.26
11.15
2.73
14.97
12.41
36.39
0.28
6.13
18.86
6.47
1.97
1.75
10.63
19.24
0.75
0.07
2.95
1.27
0.62
5.61
1.40
4.25
1.51
2.02
3.08
2.46
2.83
3.53

RENTAL
FEE

BR

CODE
A4637
A4640
A4649
A4660
A4670
A4670
A4927
A4930
A4931
A4932
A5051
A5052
A5053
A5054
A5055
A5056
A5057
A5061
A5062
A5063
A5071
A5072
A5073
A5081
A5082
A5083
A5093
A5105
A5112
A5113
A5114
A5120
A5121
A5122
A5126
A5131
A5200
A5500
A5501
A5503
A5504
A5505
A5506
A5507
A5512
A5513
A6010
A6011

DESCRIPTION
REPLACEMENT, TIP, CANE, CRUTCH, WALKER,
REPLACEMENT PAD FOR USE WITH MEDICALLY
SURGICAL SUPPLY MISC
SPHYGMOMANOMETER/BLOOD PRESSURE APPARATU
AUTOMATIC BLOOD PRESSURE MONITOR - SEMI AUTO
AUTOMATIC BLOOD PRESSURE MONITOR- FULLY AUTO
GLOVES, NON-STERILE, PER 100
GLOVES,STERILE PER PAIR
ORAL THERMOMETER, REUSABLE, ANY TYPE, EA
RECTAL THERMOMETER, REUSABLE, ANY TYPE,
OSTOMY POUCH, CLOSED; WITH BARRIER ATTAC
OSTOMY POUCH, CLOSED; WITHOUT BARRIER AT
OSTOMY POUCH, CLOSED; FOR USE ON FACEPLA
OSTOMY POUCH, CLOSED; FOR USE ON BARRIER
STOMA CAP EACH
OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR
OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR
OSTOMY POUCH, DRAINABLE; WITH BARRIER AT
OSTOMY POUCH, DRAINABLE; WITHOUT BARRIER
OSTOMY POUCH, DRAINABLE; FOR USE ON BARR
OSTOMY POUCH, URINARY; WITH BARRIER ATTA
OSTOMY POUCH, URINARY; WITHOUT BARRIER A
OSTOMY POUCH, URINARY; FOR USE ON BARRIE
CONTINENT DEVICE; PLUG FOR CONTINENT STO
CONTINENT DEVICE; CATHETER FOR CONTINENT
CONTINENT DEVICE, STOMA ABSORPTIVE COVER
OSTOMY ACCESSORY CONVEX INSERT
URINARY SUSPENSORY WITH LEG BAG, WITH OR
URINARY DRAINAGE BAG, LEG OR ABDOMEN, LA
LEG STRAP; LATEX, REPLACEMENT ONLY, PER
LEG STRAP; FOAM OR FABRIC, REPLACEMENT
SKIN BARRIER, WIPES OR SWABS, EACH
SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT
SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT
ADHESIVE OR NON-ADHESIVE; DISK OR FOAM
APPLIANCE CLEANER, INCONTINENCE AND OSTO
PERCUTANEOUS CATHETER/TUBE ANCHORING DEV
FOR DIABETICS ONLY, FITTING
FOR DIABETICS ONLY, FITTING, CUSTOM PREPARATIO
FOR DIABETICS ONLY, MODIFICATION (OF OFF-THE-S
FOR DIABETICS ONLY, MODIFICATION ) OF OFF-THE-S
FOR DIABETICS ONLY, MODIFICATION OF OFF-THE-SH
DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WIT
FOR DIABETICS ONLY, NOT OTHERWISE SPECIFIED M
FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, D
FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CU
COLLAGEN BASED WOUND FILLER, DRY FORM, S
COLLAGEN BASED WOUND FILLER, GEL/PASTE,

FEE
1.64
38.83
20.59
31.00
65.00
4.55
0.40
1.97
1.34
2.17
1.56
1.73
1.68
1.49
5.01
10.32
3.37
2.33
2.27
4.41
3.70
3.20
3.37
10.60
0.22
1.87
42.76
29.64
1.86
3.92
0.20
6.65
11.95
1.16
8.06
2.70
66.69
200.05
32.60
32.60
32.60
32.60
32.60
27.21
40.61
4.51
2.39

RENTAL
FEE

BR

CODE
A6021
A6022
A6023
A6024
A6196
A6197
A6198
A6199
A6203
A6204
A6205
A6206
A6207
A6208
A6209
A6210
A6211
A6212
A6213
A6214
A6216
A6217
A6218
A6219
A6220
A6221
A6222
A6223
A6224
A6228
A6229
A6230
A6231
A6232
A6233
A6234
A6235
A6236
A6237
A6238
A6239
A6240
A6241
A6242
A6243
A6244
A6245
A6246

DESCRIPTION
COLLAGEN DRESSING, STERILE, SIZE 16 SQUARE
COLLAGEN DRESSING, STERILE, SIZE MORE THA
COLLAGEN DRESSING, STERILE, SIZE MORE THA
COLLAGEN DRESSING WOUND FILLER, STERILE,
ALGINATE OR OTHER FIBER GELLING DRESSING
ALGINATE OR OTHER FIBER GELLING DRESSING
ALGINATE OR OTHER FIBER GELLING DRESSING
ALGINATE OR OTHER FIBER GELLING DRESSING
COMPOSITE DRESSING, STERILE, PAD SIZE 16
COMPOSITE DRESSING, STERILE, PAD SIZE MO
COMPOSITE DRESSING, STERILE, PAD SIZE MO
CONTACT LAYER, STERILE, 16 SQ. IN. OR LE
CONTACT LAYER, STERILE, MORE THAN 16 SQ.
CONTACT LAYER, STERILE, MORE THAN 48 SQ.
FOAM DRESSING, WOUND COVER, STERILE, PAD
FOAM DRESSING, WOUND COVER, STERILE, PAD
FOAM DRESSING, WOUND COVER, STERILE, PAD
FOAM DRESSING, WOUND COVER, STERILE, PAD
FOAM DRESSING, WOUND COVER, STERILE, PAD
FOAM DRESSING, WOUND COVER, STERILE, PAD
GAUZE NON-IMP NON-STER UP TO 1
A6216; MORE THAN 16 UP TO 48SQ
A6216; MORE THAN 48 SQ IN
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ
GAUZE, IMPREGNATED WITH OTHER THAN WATER
GAUZE, IMPREGNATED WITH OTHER THAN WATER
GAUZE, IMPREGNATED WITH OTHER THAN WATER
GAUZE, IMPREGNATED, WATER OR NORMAL SALI
GAUZE, IMPREGNATED, WATER OR NORMAL SALI
GAUZE, IMPREGNATED, WATER OR NORMAL SALI
GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT
GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT
GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT
HYDROCOLLOID DRESSING, WOUND COVER, STER
HYDROCOLLOID DRESSING, WOUND COVER, STER
HYDROCOLLOID DRESSING, WOUND COVER, STER
HYDROCOLLOID DRESSING, WOUND COVER, STER
HYDROCOLLOID DRESSING, WOUND COVER, STER
HYDROCOLLOID DRESSING, WOUND COVER, STER
HYDROCOLLOID DRESSING, WOUND FILLER, PAS
HYDROCOLLOID DRESSING, WOUND FILLER, DRY
HYDROGEL DRESSING, WOUND COVER, STERILE,
HYDROGEL DRESSING, WOUND COVER, STERILE,
HYDROGEL DRESSING, WOUND COVER, STERILE,
HYDROGEL DRESSING, WOUND COVER, STERILE,
HYDROGEL DRESSING, WOUND COVER, STERILE,

FEE
19.88
22.05
76.88
4.39
5.50
6.43
14.52
2.76
2.11
4.09
5.65
1.53
2.68
6.50
1.66
3.57
8.09
3.99
9.06
10.79
0.04
0.08
0.19
0.22
1.08
2.42
1.44
1.71
1.79
1.62
1.69
1.82
1.32
4.01
5.57
5.69
11.26
13.88
5.11
8.20
10.54
8.12
1.59
3.06
6.49
14.05
3.56
7.39

RENTAL
FEE

BR

CODE
A6247
A6248
A6251
A6252
A6253
A6254
A6255
A6256
A6257
A6258
A6259
A6261
A6262
A6266
A6402
A6403
A6404
A6407
A6410
A6411
A6412
A6441
A6442
A6443
A6444
A6445
A6446
A6447
A6448
A6449
A6450
A6451
A6452
A6453
A6454
A6455
A6456
A6457
A6501
A6502
A6503
A6504
A6505
A6506
A6507
A6508
A6509
A6510

DESCRIPTION
HYDROGEL DRESSING, WOUND COVER, STERILE,
HYDROGEL DRESSING, WOUND FILLER, GEL, PE
SPECIALTY ABSORPTIVE DRESSING, WOUND COV
SPECIALTY ABSORPTIVE DRESSING, WOUND COV
SPECIALTY ABSORPTIVE DRESSING, WOUND COV
SPECIALTY ABSORPTIVE DRESSING, WOUND COV
SPECIALTY ABSORPTIVE DRESSING, WOUND COV
SPECIALTY ABSORPTIVE DRESSING, WOUND COV
TRANSPARENT FILM, STERILE, 16 SQ. IN. OR
TRANSPARENT FILM, STERILE, MORE THAN 16
TRANSPARENT FILM, STERILE, MORE THAN 48
WOUND FILLER, GEL/PASTE, PER FLUID OUNCE
WOUND FILLER, DRY FORM, PER GRAM, NOT OT
GAUZE, IMPREGNATED, OTHER THAN WATER, NO
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ
PACKING STRIPS, NON-IMPREGNATED, STERILE
EYE PAD, STERILE, EACH
EYE PAD,NON-STERILE, EACH
EYE PATCH, OCCLUSIVE, EACH
PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/
CONFORMING BANDAGE, NON-ELASTIC, KNITTED
CONFORMING BANDAGE, NON-ELASTIC, KNITTED
CONFORMING BANDAGE, NON-ELASTIC, KNITTED
CONFORMING BANDAGE, NON-ELASTIC, KNITTED
CONFORMING BANDAGE, NON-ELASTIC, KNITTED
CONFORMING BANDAGE, NON-ELASTIC, KNITTED
LIGHT COMPRESSION BANDAGE, ELASTIC, KNIT
LIGHT COMPRESSION BANDAGE, ELASTIC, KNIT
LIGHT COMPRESSION BANDAGE, ELASTIC, KNIT
MODERATE COMPRESSION BANDAGE, ELASTIC, K
HIGH COMPRESSION BANDAGE, ELASTIC, KNITT
SELF-ADHERENT BANDAGE, ELASTIC, NON-KNIT
SELF-ADHERENT BANDAGE, ELASTIC, NON-KNIT
SELF-ADHERENT BANDAGE, ELASTIC, NON-KNIT
ZINC PASTE IMPREGNATED BANDAGE, NON-ELAS
TUBULAR DRESSING WITH OR WITHOUT ELASTIC
COMPRESSION BURN GARMENT, BODYSUIT (HEAD
COMPRESSION BURN GARMENT, CHIN STRAP, CU
COMPRESSION BURN GARMENT, FACIAL HOOD, C
COMPRESSION BURN GARMENT, GLOVE TO WRIST
COMPRESSION BURN GARMENT, GLOVE TO ELBOW
COMPRESSION BURN GARMENT, GLOVE TO AXILL
COMPRESSION BURN GARMENT, FOOT TO KNEE L
COMPRESSION BURN GARMENT, FOOT TO THIGH
COMPRESSION BURN GARMENT, UPPER TRUNK TO
COMPRESSION BURN GARMENT, TRUNK, INCLUDI

FEE
18.77
4.16
2.09
2.54
3.61
1.07
1.71
3.85
0.35
1.16
2.46

2.02
0.13
0.26
0.35
1.91
0.23
0.16
0.27
0.70
0.04
0.06
0.08
0.06
0.10
0.18
0.06
0.09
0.16
0.17
1.22
0.40
0.57
0.68
0.80
1.20

RENTAL
FEE

BR

CODE
A6511
A6512
A6530
A6531
A6532
A6533
A6534
A6535
A6536
A6537
A6538
A6539
A6540
A6541
A6544
A6549
A7000
A7002
A7003
A7004
A7005
A7007
A7013
A7014
A7015
A7025
A7026
A7027
A7028
A7029
A7030
A7031
A7032
A7033
A7034
A7035
A7036
A7037
A7038
A7039
A7044
A7045
A7520
A7521
A7522
A7523
A7524
A7525

DESCRIPTION
COMPRESSION BURN GARMENT, LOWER TRUNK IN
COMPRESSION BURN GARMET NOC
GRADIENT COMPRESSION STOCKING, BELOW KNE
GRADIENT COMPRESSION STOCKING, BELOW KNE
GRADIENT COMPRESSION STOCKING, BELOW KNE
GRADIENT COMPRESSION STOCKING, THIGH LEN
GRADIENT COMPRESSION STOCKING, THIGH LEN
GRADIENT COMPRESSION STOCKING, THIGH LEN
GRADIENT COMPRESSION STOCKING, FULL LENG
GRADIENT COMPRESSION STOCKING, FULL LENG
GRADIENT COMPRESSION STOCKING, FULL LENG
GRADIENT COMPRESSION STOCKING, WAIST LEN
GRADIENT COMPRESSION STOCKING, WAIST LEN
GRADIENT COMPRESSION STOCKING, WAIST LEN
GRADIENT COMPRESSION STOCKING, GARTER BE
GRADIENT COMPRESSION STOCKING/SLEEVE, NO
CANISTER, DISPOSABLE, USED WITH SUCTION
TUBING, USED WITH SUCTION PUMP, EACH
ADMINISTRATION SET, WITH SMALL VOLUME NO
SMALL VOLUME NONFILTERED PNEUMATIC NEBUL
ADMINISTRATION SET, WITH SMALL VOLUME NO
LARGE VOLUME NEBULIZER, DISPOSABLE, UNFI
FILTER, DISPOSABLE, USED WITH AEROSOL CO
FILTER, NONDISPOSABLE, USED WITH AEROSOL
AEROSOL MASK, USED WITH DME NEBULIZER
HIGH FREQUENCY CHEST WALL OSCILLATION SY
HIGH FREQUENCY CHEST WALL OSCILLATION SY
COMBINATION ORAL/NASAL MASK, USED WITH C
ORAL CUSHION FOR COMBINATION ORAL/NASAL
NASAL PILLOWS FOR COMBINATION ORAL/NASAL
FULL FACE MASK USED WITH POSITIVE AIRWAY
FACE MASK INTERFACE, REPLACEMENT FOR FUL
CUSHION FOR USE ON NASAL MASK INTERFACE,
PILLOW FOR USE ON NASAL CANNULA TYPE INT
NASAL INTERFACE (MASK OR CANNULA TYPE) U
HEADGEAR USED WITH POSITIVE AIRWAY PRESS
CHINSTRAP USED WITH POSITIVE AIRWAY PRES
TUBING USED WITH POSITIVE AIRWAY PRESSUR
FILTER, DISPOSABLE, USED WITH POSITIVE A
FILTER, NON DISPOSABLE, USED WITH POSITI
ORAL INTERFACE USED WITH POSITIVE AIRWAY
EXHALATION PORT WITH OR WITHOUT SWIVEL U
TRACHEOSTOMY/LARYNGECTOMY TUBE, NON-CUFF
TRACHEOSTOMY/LARYNGECTOMY TUBE, CUFFED,
TRACHEOSTOMY/LARYNGECTOMY TUBE, STAINLES
TRACH SHOWER PROTECTOR,EACH
TRACHEOSTOMA STENT/STUD/BUTTON, EACH
TRACHEOSTOMY MASK,EACH

FEE

18.06
18.88
26.96
22.31
26.61
31.71
31.47
33.24
43.22
62.72
101.23
104.94
15.00
4.35
0.92
2.23
1.29
16.19
2.89
0.11
0.80
1.06
275.00
28.75
179.35
49.54
20.24
143.21
63.08
36.64
25.68
48.86
29.55
14.10
21.16
1.71
2.40
109.31
17.60
49.80
49.35
47.37
8.10
59.63
1.68

RENTAL
FEE

BR

CODE
A8000
A8001
A8002
A8003
A8004
A9273
A9275
A9282
A9900
A9999
B4034
B4035
B4036
B4081
B4082
B4083
B4087
B4088
B4100
B4149
B4150
B4152
B4153
B4154
B4155
B4157
B4158
B4159
B4160
B4161
B4162
B9002
B9004
B9006
B9998
E0100
E0105
E0110
E0111
E0112
E0113
E0114
E0116
E0130
E0135
E0140
E0141
E0143

DESCRIPTION
HELMET, PROTECTIVE, SOFT, PREFABRICATED,
HELMET, PROTECTIVE, HARD, PREFABRICATED,
HELMET, PROTECTIVE, SOFT, CUSTOM FABRICA
HELMET, PROTECTIVE, HARD, CUSTOM FABRICA
SOFT INTERFACE FOR HELMET, REPLACEMENT O
HOT WATER BOTTLE, ICE CAP OR COLLAR, HEA
HOME GLUCOSE DISPOSABLE MONITOR, INCLUDE
WIG, ANY TYPE, EACH
MISCELLANEOUS DME SUPPLY, ACCESSORY, AND
MISCELLANEOUS DME SUPPLY OR ACCESSORY, N
ENTERAL FEEDING SUPPLY KIT; SYRINGE FED,
ENTERAL FEEDING SUPPLY KIT; PUMP FED, PE
ENTERAL FEEDING SUPPLY KIT; GRAVITY FED,
NASOGASTRIC TUBING WITH STYLET
NASOGASTRIC TUBING WITHOUT STYLET
STOMACH TUBE-LEVINE TYPE
GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD,
GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFIL
FOOD THICKENER, ADMINISTERED ORALLY, PER
ENTERAL FORMULA, MANUFACTURED BLENDERIZE
ENTERAL FORMULA, NUTRITIONALLY COMPLETE
ENTERAL FORMULA, NUTRITIONALLY COMPLETE,
ENTERAL FORMULA, NUTRITIONALLY COMPLETE,
ENTERAL FORMULA, NUTRITIONALLY COMPLETE,
ENTERAL FORMULA, NUTRITIONALLY INCOMPLET
ENTERAL FORMULA, NUTRITIONALLY COMPLETE,
ENTERAL FORMULA, FOR PEDIATRICS, NUTRITI
ENTERAL FORMULA, FOR PEDIATRICS, NUTRITI
ENTERAL FORMULA, FOR PEDIATRICS, NUTRITI
ENTERAL FORMULA, FOR PEDIATRICS, HYDROLY
ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL
ENTERAL NUTRITION INFUSION PUMP - WITH A
PARENTERAL NUTRITION INFUSION PUMP, PORT
PARENTERAL NUTRITION INFUSION PUMP, STAT
NOC FOR ENTERAL SUPPLIES
CANE, INCLUDES CANES OF ALL MATERIALS, A
CANE, QUAD OR THREE PRONG, INCLUDES CANE
CRUTCHES, FOREARM, INCLUDES CRUTCHES OF
CRUTCH FOREARM, INCLUDES CRUTCHES OF VAR
CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR F
CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIX
CRUTCHES UNDERARM, OTHER THAN WOOD, ADJU
CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUS
WALKER, RIGID (PICKUP), ADJUSTABLE OR FI
WALKER, FOLDING (PICKUP), ADJUSTABLE OR
WALKER, WITH TRUNK SUPPORT, ADJUSTABLE O
WALKER, RIGID, WHEELED, ADJUSTABLE OR FI
WALKER, FOLDING, WHEELED, ADJUSTABLE OR

FEE

RENTAL
FEE

BR

116.10
151.65
426.00
426.00
5.40
28.75
110.84

3.12
5.66
4.30
16.17
10.06
1.07
22.89
134.58
0.53
0.99
0.49
0.38
1.85
0.85
1.21
4.58
0.73
0.84
0.60
1.35
4.58
715.56
2748.36
2039.92

BR SC
BR SC
BR SC

BR SC
BR SC
60.00
60.00
60.00

12.00
18.75
58.93
29.46
23.93
11.96
23.38
11.69
37.33
47.63
100.00
104.24
92.21

CODE
E0144
E0147
E0148
E0149
E0153
E0154
E0155
E0156
E0157
E0159
E0160
E0163
E0165
E0167
E0168
E0175
E0181
E0182
E0184
E0185
E0186
E0187
E0188
E0190
E0191
E0193
E0196
E0197
E0198
E0199
E0202
E0210
E0215
E0235
E0240
E0241
E0243
E0244
E0245
E0246
E0247
E0248
E0251
E0256
E0261
E0266
E0271
E0272

DESCRIPTION
WALKER, ENCLOSED, FOUR SIDED FRAMED, RIG
WALKER, HEAVY DUTY, MULTIPLE BRAKING SYS
WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGI
WALKER, HEAVY DUTY, WHEELED, RIGID OR FO
PLATFORM ATTACHMENT, FOREARM CRUTCH, EAC
PLATFORM ATTACHMENT,WALKER,EACH
WHEEL ATTACHMENT, RIGID PICK-UP WALKER,
SEAT ATTACHMENT, WALKER
CRUTCH ATTACHMENT, WALKER, EACH
BRAKE ATTACHMENT FOR WHEELED WALKER, REP
SITZ TYPE BATH OR EQUIPMENT, PORTABLE, U
COMMODE CHAIR, MOBILE OR STATIONARY, WIT
COMMODE CHAIR, MOBILE OR STATIONARY, WIT
PAIL OR PAN FOR USE WITH COMMODE CHAIR,
COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY D
FOOT REST, FOR USE WITH COMMODE CHAIR, E
POWERED PRESSURE REDUCING MATTRESS OVERL
PUMP FOR ALTERNATING PRESSURE PAD, FOR R
DRY PRESSURE MATTRESS
GEL OR GEL-LIKE PRESSURE PAD FOR MATTRES
AIR PRESSURE MATTRESS
WATER PRESSURE MATTRESS
SYNTHETIC SHEEPSKIN PAD
POSITIONING CUSHION/PILLOW/WEDGE, ANY SH
HEEL OR ELBOW PROTECTOR EACH
POWERED AIR FLOTATION BED (LOW AIR LOSS
GEL PRESSURE MATTRESS
AIR PRESSURE PAD FOR MATTRESS, STANDARD
WATER PRESSURE PAD FOR MATTRESS, STANDAR
DRY PRESSURE PAD FOR MATTRESS, STANDARD
PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOT
ELECTRIC HEAT PAD, STANDARD
ELECTRIC HEAT PAD MOIST
PARAFFIN BATH UNIT, PORTABLE (SEE MEDICA
BATH/SHOWER CHAIR, WITH OR WITHOUT WHEEL
BATHTUB WALL RAIL EACH
TOILET RAIL EACH
RAISED TOILET SEAT
TUB STOOL OR BENCH
TRANSFER TUB RAIL ATTACHMENT
TRANSFER BENCH FOR TUB OR TOILET WITH OR
TRANSFER BENCH, HEAVY DUTY, FOR TUB OR T
HOSPITAL BED, FIXED HEIGHT, WITH ANY TYP
HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WI
HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FO
HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT
MATTRESS, INNERSPRING
MATTRESS, FOAM RUBBER

FEE
287.91
306.70
114.87
201.80
61.29
57.15
24.25
23.90
20.09
14.92
4.31
103.63
174.18
6.08
153.52
59.05
121.46
88.65
153.13
165.74
91.55
61.20
19.50
22.04
2.81
4543.50
74.00
64.63
40.23
19.48
10.00
14.40
20.93
59.94
38.34
27.07
35.87
20.99
28.79
48.10
89.83
170.34
288.81
450.06
713.97
863.68
157.21
155.52

RENTAL
FEE

15.31
9.16
6.12

454.35
7.40

10.00

28.89
45.01
71.40
86.37
15.72
15.55

BR

CODE
E0274
E0275
E0276
E0277
E0301
E0302
E0305
E0310
E0316
E0325
E0326
E0328
E0371
E0372
E0424
E0431
E0434
E0439
E0445
E0465
E0466
E0470
E0471
E0472
E0480
E0481
E0482
E0483
E0500
E0550
E0561
E0562
E0565
E0570
E0575
E0580
E0600
E0601
E0602
E0603
E0604
E0605
E0607
E0619
E0621
E0628
E0629
E0630

DESCRIPTION
TABLE, OVERBED
BED PAN STANDARD METAL OR PLASTIC
BED PAN FRACTURE METAL OR PLASTIC
POWERED PRESSURE-REDUCING AIR MATTRESS
HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WI
HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WI
BED SIDE RAILS, HALF LENGTH
BED SIDE RAILS, FULL LENGTH
SAFETY ENCLOSURE FRAME/CANOPY FOR USE WI
URINAL MALE JUG-TYPE ANY MATERIAL
URINAL FEMALE JUG-TYPE ANY MATERIAL
HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEG
NONPOWERED ADVANCED PRESSURE REDUCING OV
POWERED AIR OVERLAY FOR MATTRESS, STANDA
STATIONARY COMPRESSED GASEOUS OXYGEN SYS
PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL;
PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; I
STATIONARY LIQUID OXYGEN SYSTEM, RENTAL;
OXIMETER DEVICE FOR MEASURING BLOOD OXYG
HOME VENTILATOR, ANY TYPE, USED WITH INVASIVE
HOME VENTILATOR, ANY TYPE, USED WITH NON- INVASIVE INT
RESPIRATORY ASSIST DEVICE, BI-LEVEL PRES
RESPIRATORY ASSIST DEVICE, BI-LEVEL PRES
RESPIRATORY ASSIST DEVICE, BI-LEVEL PRES
PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME M
INTRAPULMONARY PERCUSSIVE VENTILATION SY
COUGH STIMULATING DEVICE, ALTERNATING PO
HIGH FREQUENCY CHEST WALL OSCILLATION AI
IPPB MACHINE, ALL TYPES, WITH BUILT-IN
HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLE
HUMIDIFIER, NON-HEATED, USED WITH POSITI
HUMIDIFIER, HEATED, USED WITH POSITIVE A
COMPRESSOR, AIR POWER SOURCE FOR EQUIPME
NEBULIZER, WITH COMPRESSOR
NEBULIZER; ULTRASONIC
NEBULIZER, DURABLE, GLASS OR AUTOCLAVABL
RESPIRATORY SUCTION PUMP, HOME MODEL, PO
CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE
BREAST PUMP, MANUAL, ANY TYPE
BREAST PUMP ELECTRIC (AC/DC), ANY TYPE
BREAST PUMP, HOSPITAL GRADE, ELECTRIC (A
VAPORIZER,ROOM TYPE
HOME BLOOD GLUCOSE MONITOR
APNEA MONITOR W/RECORDING FEATURE
SLING OR SEAT,PATIENT LIFT, CANVAS OR NYLON
SEPARATE SEAT LIFT MECHANISM FOR USE WIT
SEPARATE SEAT LIFT MECHANISM FOR USE WIT
PATIENT LIFT, HYDRAULIC OR MECHANICAL, I

FEE
101.85
3.78
4.25
3961.75
2206.15
4865.84
95.24
115.35
2.99
7.20
4457.81
3801.20
1412.00
100.00
30.42
45.00
72.50
165.00
731.00
731.00
2088.50
190.00
190.00
355.56
190.00
190.00
195.00
1524.17
136.64
96.74
186.33
377.69
117.89
433.91
105.38
290.66
496.20
31.71
173.47
38.61
16.73
0.00
190.00
76.59
189.00
133.50
1035.36

RENTAL
FEE

396.18
220.62
486.58

445.78
380.12
141.20
100.00
30.42
45.00
72.50
165.00
731.00
731.00
190.00
190.00
190.00
35.55
190.00
190.00
195.00
13.66
9.67
18.63
37.77

49.62

38.61

190.00

BR

CODE
E0637
E0638
E0641
E0642
E0650
E0655
E0660
E0665
E0666
E0700
E0705
E0710
E0730
E0747
E0748
E0760
E0776
E0781
E0784
E0791
E0849
E0855
E0860
E0890
E0900
E0910
E0911
E0912
E0940
E0944
E0946
E0950
E0951
E0952
E0955
E0956
E0957
E0958
E0959
E0960
E0961
E0966
E0967
E0971
E0973
E0974
E0978
E0986

DESCRIPTION
COMBINATION SIT TO STAND SYSTEM, ANY SIZ
STANDING FRAME SYSTEM, ONE POSITION (E.G
STANDING FRAME SYSTEM, MULTI-POSITION (E
STANDING FRAME SYSTEM, MOBILE (DYNAMIC S
PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME
NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US
NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US
NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US
NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US
SAFETY EQUIPMENT, DEVICE OR ACCESSORY, A
TRANSFER DEVICE, ANY TYPE, EACH
RESTRAINTS, ANY TYPE (BODY, CHEST, WRIST
TRANSCUTANEOUS ELECTRICAL NERVE STIMULAT
OSTEOGENESIS STIMULATOR, ELECTRICAL, NON
OSTEOGENESIS STIMULATOR, ELECTRICAL, NON
OSTEOGENESIS STIMULATOR, LOW INTENSITY U
IV POLE
AMBULATORY INFUSION PUMP, SINGLE OR MULT
EXTERNAL AMBULATORY INFUSION PUMP, INSUL
PARENTERAL INFUSION PUMP, STATIONARY, SI
TRACTION EQUIPMENT, CERVICAL, FREE-STAND
CERVICAL TRACTION EQUIPMENT NOT REQUIRIN
TRACTION EQUIPMENT, OVERDOOR, CERVICAL
TRACTION FRAME, ATTACHED TO FOOTBOARD, P
TRACTION STAND, FREE STANDING, PELVIC TR
TRAPEZE BARS, A/K/A PATIENT HELPER, ATTA
TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEI
TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEI
TRAPEZE BAR, FREE STANDING, COMPLETE WIT
PELVIC BELT/HARNESS/BOOT
FRACTURE, FRAME, DUAL WITH CROSS BARS, A
WHEELCHAIR ACCESSORY, TRAY, EACH
HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITH
TOE LOOP/HOLDER, ANY TYPE, EACH
WHEELCHAIR ACCESSORY, HEADREST, CUSHIONE
WHEELCHAIR ACCESSORY, LATERAL TRUNK OR H
WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPO
MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRI
MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR
WHEELCHAIR ACCESSORY, SHOULDER HARNESS/S
MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK
MANUAL WHEELCHAIR ACCESSORY, HEADREST EX
MANUAL WHEELCHAIR ACCESSORY, HAND RIM WI
MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPIN
WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT,
MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBA
WHEELCHAIR ACCESSORY, POSITIONING BELT/S
MANUAL WHEELCHAIR ACCESSORY, PUSH ACTIVA

FEE
3229.11
1273.22
1663.88
531.06
56.04
166.98
135.15
89.56
15.15
37.22
13.65
76.25
3,300.00
3,300.00
2,700.00
127.64
2647.67
4399.30
2039.92
371.70
502.63
21.36
80.83
78.54
173.33
432.00
742.07
254.98
40.90
514.42
148.97
17.16
17.02
182.79
89.12
124.71
45.06
81.20
16.13
60.45
65.66
37.92
92.39
44.55
29.39

RENTAL
FEE
322.91
127.32
166.39

BR

BR
BR
BR
BR
BR

BR
BR
BR
12.76
60.00
60.00
37.17
50.26

17.33
43.20
74.21
25.50
51.44

CODE
E0990
E0992
E0995
E1002
E1003
E1004
E1005
E1006
E1007
E1008
E1009
E1010
E1011
E1012
E1014
E1020
E1028
E1161
E1225
E1226
E1228
E1229
E1233
E1234
E1298
E1390
E1392
E1399
E1399
E1399
E1399
E1399
E2100
E2201
E2202
E2203
E2204
E2205
E2206
E2207
E2209
E2210
E2211
E2212
E2213
E2214
E2215
E2218

DESCRIPTION
WHEELCHAIR ACCESSORY, ELEVATING LEG REST
MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT
WHEELCHAIR ACCESSORY, CALF REST/PAD, EAC
WHEELCHAIR ACCESSORY, POWER SEATING SYST
WHEELCHAIR ACCESSORY, POWER SEATING SYST
WHEELCHAIR ACCESSORY, POWER SEATING SYST
WHEELCHAIR ACCESSORY, POWER SEATNG SYSTE
WHEELCHAIR ACCESSORY, POWER SEATING SYST
WHEELCHAIR ACCESSORY, POWER SEATING SYST
WHEELCHAIR ACCESSORY, POWER SEATING SYST
WHEELCHAIR ACCESSORY, ADDITION TO POWER
WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SY
MODIFICATION TO PEDIATRIC SIZE WHEELCHAI
WHEELCHAIR ACCESSORY,ADDITION TO POWER SEATING
RECLINING BACK, ADDITION TO PEDIATRIC SI
RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCH
WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY,
MANUAL ADULT SIZE WHEELCHAIR, INCLUDES T
WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLIN
WHEELCHAIR ACCESSORY, MANUAL FULLY RECLI
SPECIAL BACK HEIGHT FOR WHEELCHAIR
WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWIS
WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPAC
WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPAC
SPECIAL WHEELCHAIR SEAT DEPTH AND/OR WID
OXYGEN CONCENTRATOR, SINGLE DELIVERY POR
PORTABLE OXYGEN CONCENTRATOR, RENTAL
DURABLE MEDICAL EQUIPMENT,MISC
Positioning bath chair, small/medium
Positioning bath chair, large
Positioning bath chair tub stand addition
Positioning bath chair shower stand addition
BLOOD GLUCOSE MONITOR WITH INTEGRATED VO
MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD
MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD
MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD
MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD
MANUAL WHEELCHAIR ACCESSORY, HANDRIM WIT
MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK
WHEELCHAIR ACCESSORY, CRUTCH AND CANE HO
ARM TROUGH, WITH OR WITHOUT HAND SUPPORT
WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE
MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC P
MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PN
MANUAL WHEELCHAIR ACCESSORY, INSERT FOR
MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC C
MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PN
MANUAL WHEELCHAIR ACCESSORY, FOAM PROPUL

FEE
106.16
70.88
23.21

365.14
220.07

RENTAL
FEE
10.62

36.51

2287.24
491.09

49.11

2451.60
2362.05
150.00
195.00
295.91
320.56
84.44
205.76
59.06
326.4
414.4
418.4
711.2
29.40
39.31
43.50
96.88
5.92
15.00
5.51
31.89
11.21
5.60
38.00

150.00
195.00

BR

CODE
E2219
E2220
E2221
E2222
E2224
E2225
E2226
E2231
E2291
E2292
E2300
E2310
E2311
E2312
E2313
E2323
E2324
E2325
E2326
E2327
E2328
E2329
E2330
E2340
E2341
E2342
E2343
E2358
E2359
E2360
E2361
E2362
E2363
E2364
E2365
E2366
E2367
E2368
E2369
E2370
E2371
E2373
E2374
E2375
E2376
E2377
E2378
E2381

DESCRIPTION
MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER
MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBB
MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBB
MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBB
MANUAL WHEELCHAIR ACCESSORY, PROPULSION
MANUAL WHEELCHAIR ACCESSORY, CASTER WHEE
MANUAL WHEELCHAIR ACCESSORY, CASTER FORK
MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT
BACK, PLANAR, FOR PEDIATRIC SIZE WHEELCH
SEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCH
WHEELCHAIR ACCESORRY, POWER SEAT ELEVATION SYSTE
POWER WHEELCHAIR ACCESSORY, ELECTRONIC C
POWER WHEELCHAIR ACCESSORY, ELECTRONIC C
POWER WHEELCHAIR ACCESSORY, HAND OR CHIN
POWER WHEELCHAIR ACCESSORY, HARNESS FOR
POWER WHEELCHAIR ACCESSORY, SPECIALTY JO
POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR
POWER WHEELCHAIR ACCESSORY, SIP AND PUFF
POWER WHEELCHAIR ACCESSORY, BREATH TUBE
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL
POWER WHEELCHAIR ACCESSORY, NONSTANDARD
POWER WHEELCHAIR ACCESSORY, NONSTANDARD
POWER WHEELCHAIR ACCESSORY, NONSTANDARD
POWER WHEELCHAIR ACCESSORY, NONSTANDARD
POWER WHEELCHAIR ACCESSORY, GROUP 34 NON
POWER WHEELCHAIR ACCESSORY, GROUP 34 SEAL
POWER WHEELCHAIR ACCESSORY, 22 NF NON-SE
POWER WHEELCHAIR ACCESSORY, 22NF SEALED
POWER WHEELCHAIR ACCESSORY, GROUP 24 NON
POWER WHEELCHAIR ACCESSORY, GROUP 24 SEA
POWER WHEELCHAIR ACCESSORY, U-1 NON-SEAL
POWER WHEELCHAIR ACCESSORY, U-1 SEALED L
POWER WHEELCHAIR ACCESSORY, BATTERY CHAR
POWER WHEELCHAIR ACCESSORY, BATTERY CHAR
POWER WHEELCHAIR COMPONENT, DRIVE WHEEL
POWER WHEELCHAIR COMPONENT, DRIVE WHEEL
POWER WHEELCHAIR COMPONENT, INTEGRATED DR
POWER WHEELCHAIR ACCESSORY, GROUP 27 SEA
POWER WHEELCHAIR ACCESSORY, HAND OR CHIN
POWER WHEELCHAIR ACCESSORY, HAND OR CHIN
POWER WHEELCHAIR ACCESSORY, NON-EXPANDAB
POWER WHEELCHAIR ACCESSORY, EXPANDABLE C
POWER WHEELCHAIR ACCESSORY, EXPANDABLE C
POWER WHEELCHAIR COMPONENT, ACTUATOR,
POWER WHEELCHAIR ACCESSORY, PNEUMATIC DR

FEE

RENTAL
FEE

BR

25.43
14.63
10.08
21.06
85.89
17.40
22.70
153.68
352.58
352.58

1939.18
307.93
62.53
39.62
1217.66
313.85
2361.84
4480.08
1596.75
3093.89
375.90

1.00
179.83
117.84
126.09
96.48
168.16
117.84
101.41
233.50
378.89
467.03
406.79
725.84
136.28
709.01
482.81
774.41
1213.54
439.13
68.87

BR

CODE
E2382
E2383
E2384
E2385
E2386
E2387
E2388
E2389
E2390
E2391
E2392
E2394
E2395
E2396
E2402
E2500
E2502
E2504
E2506
E2508
E2510
E2511
E2512
E2599
E2601
E2602
E2603
E2604
E2605
E2606
E2607
E2608
E2609
E2611
E2612
E2613
E2614
E2615
E2616
E2617
E2619
E2620
E2621
E2622
E2623
E2624
E2625
E2626

DESCRIPTION
POWER WHEELCHAIR ACCESSORY, TUBE FOR PNE
POWER WHEELCHAIR ACCESSORY, INSERT FOR P
POWER WHEELCHAIR ACCESSORY, PNEUMATIC CA
POWER WHEELCHAIR ACCESSORY, TUBE FOR PNE
POWER WHEELCHAIR ACCESSORY, FOAM FILLED
POWER WHEELCHAIR ACCESSORY, FOAM FILLED
POWER WHEELCHAIR ACCESSORY, FOAM DRIVE W
POWER WHEELCHAIR ACCESSORY, FOAM CASTER
POWER WHEELCHAIR ACCESSORY, SOLID (RUBBE
POWER WHEELCHAIR ACCESSORY, SOLID (RUBBE
POWER WHEELCHAIR ACCESSORY, SOLID (RUBBE
POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL
POWER WHEELCHAIR ACCESSORY, CASTER WHEEL
POWER WHEELCHAIR ACCESSORY, CASTER FORK,
NEGATIVE PRESSURE WOUND THERAPY ELECTRIC
SPEECH GENERATING DEVICE, DIGITIZED SPEE
SPEECH GENERATING DEVICE, DIGITIZED SPEE
SPEECH GENERATING DEVICE, DIGITIZED SPEE
SPEECH GENERATING DEVICE, DIGITIZED SPEE
SPEECH GENERATING DEVICE, SYNTHESIZED SP
SPEECH GENERATING DEVICE, SYNTHESIZED SP
SPEECH GENERATING SOFTWARE PROGRAM, FO
ACCESSORY FOR SPEECH GENERATING DEVICE,
ACCESSORY FOR SPEECH GENERATING DEVICE,
GENERAL USE WHEELCHAIR SEAT CUSHION, WID
GENERAL USE WHEELCHAIR SEAT CUSHION, WID
SKIN PROTECTION WHEELCHAIR SEAT CUSHION,
SKIN PROTECTION WHEELCHAIR SEAT CUSHION,
POSITIONING WHEELCHAIR SEAT CUSHION, WID
POSITIONING WHEELCHAIR SEAT CUSHION, WID
SKIN PROTECTION AND POSITIONING WHEELCHA
SKIN PROTECTION AND POSITIONING WHEELCHA
CUSTOM FABRICATED WHEELCHAIR SEAT CUSHIO
GENERAL USE WHEELCHAIR BACK CUSHION, WID
GENERAL USE WHEELCHAIR BACK CUSHION, WID
POSITIONING WHEELCHAIR BACK CUSHION, POS
POSITIONING WHEELCHAIR BACK CUSHION, POS
POSITIONING WHEELCHAIR BACK CUSHION, POS
POSITIONING WHEELCHAIR BACK CUSHION, POS
CUSTOM FABRICATED WHEELCHAIR BACK CUSHIO
REPLACEMENT COVER FOR WHEELCHAIR SEAT CU
POSITIONING WHEELCHAIR BACK CUSHION, PLA
POSITIONING WHEELCHAIR BACK CUSHION, PLA
SKIN PROTECTION WHEELCHAIR SEAT CUSHION,
SKIN PROTECTION WHEELCHAIR SEAT CUSHION,
SKIN PROTECTION AND POSITIONING WHEELCHA
SKIN PROTECTION AND POSITIONING WHEELCHA
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP

FEE

RENTAL
FEE

18.78
137.31
73.15
44.76
136.07
61.02
45.55
24.74
38.68
18.53
48.71
69.39
49.32
51.97
384.87
1176.89
1552.47
2276.40
3520.05
5345.62

55.29
107.95
137.05
170.34
243.36
379.66
244.22
314.70
282.40
382.02
355.34
491.77
408.94
550.21
46.39
495.17
519.64
299.68
381.33
302.14
382.49
592.43

38.49
117.69
155.25
227.64
352.00
534.56

BR

CODE
E2627
E2628
E2629
E2630
E2631
E2632
E2633
E8000
E8001
E8002
K0001
K0002
K0003
K0004
K0005
K0006
K0007
K0009
K0015
K0017
K0018
K0019
K0037
K0038
K0039
K0040
K0041
K0042
K0043
K0044
K0045
K0046
K0047
K0052
K0053
K0056
K0065
K0071
K0072
K0073
K0077
K0098
K0105
K0108
K0601
K0602
K0603
K0604

DESCRIPTION
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP
SEO, ADDITION TO MOBILE ARM SUPPORT, ELE
SEO, ADDITION TO MOBILE ARM SUPPORT, OFF
SEO, ADDITION TO MOBILE ARM SUPPORT, SUP
GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR
GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SU
GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR S
STANDARD WHEELCHAIR
STANDARD HEMI/LOW SEAT WHEELCH
LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR
WHEELCHAIR,ULTRALIGHTWEIGHT
HEAVY DUTY WHEELCHAIR
EXTRA HEAVY DUTY WHEEL CHAIR
OTHER MANUAL WHEELCHAIR
DETACHABLE, NON-ADJUSTABLE HEIGHT ARMRES
DETACHABLE, ADJUSTABLE HEIGHT
DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER
ARM PAD EACH
HIGH MOUNT FLIP-UP FOOTREST, EACH
LEG STRAP,EACH
LEG STRAP H-STYLE, EACH
ANGLE ADJUSTABLE FOOTPLATE, EACH
LARGE SIZED FOOTPLATE, EACH
STANDARD FOOTPLATE, EACH
FOOTREST, LOWER EXTENSION TUBE, EACH
FOOTREST, UPPER HANGER BRACKET, EACH
FOOTREST, COMPLETE ASSEMBLY
ELEVATING LEGREST, LOWER EXTENSION TUBE,
ELEVATING LEGREST, UPPER HANGER BRACKET,
SWINGAWAY, DETACHABLE FOOTRESTS, EACH
ELEVATING FOOTRESTS, ARTICULATING (TELES
SEAT HEIGHT LESS THAN 17" OR EQUAL TO
SPOKE PROTECTORS,EACH
FRONT CASTER ASSEMBLY, COMPLETE, WITH PN
FRONT CASTER ASSEMBLY, COMPLETE, WITH SE
CASTER PIN LOCK,EACH
FRONT CASTER ASSEMBLY, COMPLETE, WITH SO
DRIVE BELT FOR POWER WHEELCHAIR
IV HANGER, EACH
WHEELCHAIR COMPONENT OR ACCESSORY, NOT O
REPLACEMENT BATTERY FOR EXTERNAL INFUSIO
REPLACEMENT BATTERY FOR EXTERNAL INFUSIO
REPLACEMENT BATTERY FOR EXTERNAL INFUSIO
REPLACEMENT BATTERY FOR EXTERNAL INFUSIO

FEE

RENTAL
FEE

803.55
712.17
991.11
450.00
252.10
160.31
135.97

280.39
465.32
559.50
810.86
1779.08
737.03
1074.78
53.55
46.20
25.81
14.79
37.01
21.94
48.71
67.51
47.84
32.94
17.65
15.04
51.19
17.65
69.14
83.58
92.23
95.10
36.00
50.11
42.30
16.60
35.93
24.61
104.30
1.10
6.67
0.57
6.38

100.00
100.00
100.00
28.04
46.53
55.95
81.09
73.70

BR

CODE
K0605
K0606
K0730
K0739
K0800
K0801
K0802
K0806
K0807
K0808
K0812
K0813
K0814
K0815
K0816
K0820
K0821
K0822
K0823
K0824
K0825
K0826
K0827
K0828
K0829
K0835
K0836
K0837
K0838
K0839
K0840
K0841
K0842
K0843
K0848
K0849
K0850
K0851
K0852
K0853
K0854
K0855
K0856
K0857
K0858
K0859
K0860
K0861

DESCRIPTION
REPLACEMENT BATTERY FOR EXTERNAL INFUSIO
AUTOMATIC EXTERNAL DEFIBRILLATOR, WITH I
CONTROLLED DOSE INHALATION DRUG DELIVERY
REPAIR OR NON-ROUTINE SERVICE FOR DURABL
POWER OPERATED VEHICLE, GROUP 1 STANDARD
POWER OPERATED VEHICLE, GROUP 1 HEAVY DU
POWER OPERATED VEHICLE, GROUP 1 VERY HEA
POWER OPERATED VEHICLE, GROUP 2 STANDARD
POWER OPERATED VEHICLE, GROUP 2 HEAVY DU
POWER OPERATED VEHICLE, GROUP 2 VERY HEA
POWER OPERATED VEHICLE, NOT OTHERWISE CL
POWER WHEELCHAIR, GROUP 1 STANDARD, PORT
POWER WHEELCHAIR, GROUP 1 STANDARD, PORT
POWER WHEELCHAIR, GROUP 1 STANDARD, SLIN
POWER WHEELCHAIR, GROUP 1 STANDARD, CAPT
POWER WHEELCHAIR, GROUP 2 STANDARD, PORT
POWER WHEELCHAIR, GROUP 2 STANDARD, PORT
POWER WHEELCHAIR, GROUP 2 STANDARD, SLIN
POWER WHEELCHAIR, GROUP 2 STANDARD, CAPT
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SL
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CA
POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUT
POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUT
POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DU
POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DU
POWER WHEELCHAIR, GROUP 2 STANDARD, SING
POWER WHEELCHAIR, GROUP 2 STANDARD, SING
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SI
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SI
POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUT
POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DU
POWER WHEELCHAIR, GROUP 2 STANDARD, MULT
POWER WHEELCHAIR, GROUP 2 STANDARD, MULT
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MU
POWER WHEELCHAIR, GROUP 3 STANDARD, SLIN
POWER WHEELCHAIR, GROUP 3 STANDARD, CAPT
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SL
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CA
POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUT
POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUT
POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DU
POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DU
POWER WHEELCHAIR, GROUP 3 STANDARD, SING
POWER WHEELCHAIR, GROUP 3 STANDARD, SING
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SI
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SI
POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUT
POWER WHEELCHAIR, GROUP 3 STANDARD, MULT

FEE
14.60
1569.32
100.00
18.00
1168.79
1884.33
2132.46
1413.92
2145.46
3319.48
2412.40
3087.80
3516.30
3367.40
2576.60
3307.70
3997.50
4023.70
4842.70
4433.20
6269.30
5330.90
6908.20
6343.70
4057.40
4207.50
4842.70
4332.30
6269.30
9498.30
4318.60
4318.60
5199.60
5284.40
5080.70
6129.80
5893.70
7082.60
7275.60
9638.60
9105.10
5672.30
5786.00
7037.60
6711.70
10054.10
5681.40

RENTAL
FEE
1569.32
100.00

BR

CODE
K0862
K0863
K0864
K0868
K0869
K0870
K0871
K0877
K0878
K0879
K0880
K0884
K0885
K0886
K0890
K0891
K0898
L0112
L0113
L0120
L0130
L0140
L0150
L0160
L0170
L0172
L0174
L0180
L0190
L0200
L0220
L0450
L0452
L0454
L0455
L0456
L0457
L0458
L0460
L0462
L0464
L0466
L0467
L0468
L0469
L0470
L0472
L0480

DESCRIPTION
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MU
POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUT
POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DU
POWER WHEELCHAIR, GROUP 4 STANDARD, SLIN
POWER WHEELCHAIR, GROUP 4 STANDARD, CAPT
POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SL
POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUT
POWER WHEELCHAIR, GROUP 4 STANDARD, SING
POWER WHEELCHAIR, GROUP 4 STANDARD, SING
POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SI
POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUT
POWER WHEELCHAIR, GROUP 4 STANDARD, MULT
POWER WHEELCHAIR, GROUP 4 STANDARD, MULT
POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MU
POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SIN
POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MUL
POWER WHEELCHAIR, NOT OTHERWISE CLASSIFI
CRANIAL CERVICAL ORTHOSIS, CONGENITAL TO
CRANIAL CERVICAL ORTHOSIS, TORTICOLLIS T
CERVICAL, FLEXIBLE, NON-ADJUSTABLE (FOAM
CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR
CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTI
CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED
CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPIT
CERVICAL, COLLAR, MOLDED TO PATIENT MODE
CERVICAL, COLLAR, SEMI-RIGID THERMOPLAST
CERVICAL, COLLAR, SEMI-RIGID, THERMOPLAS
CERVICAL, MULTIPLE POST COLLAR, OCCIPITA
CERVICAL, MULTIPLE POST COLLAR, OCCIPITA
CERVICAL, MULTIPLE POST COLLAR, OCCIPITA
THORACIC, RIB BELT, CUSTOM FABRICATED
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT,
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT,
TLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, E
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, E
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT,
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC
TLSO, TRIPLANAR CONTROL, MODULAR SEGMENT
TLSO, TRIPLANAR CONTROL, MODULAR SEGMENT
TLSO, TRIPLANAR CONTROL, MODULAR SEGMENT
TLSO, TRIPLANAR CONTROL, MODULAR SEGMENT
TLSO, SAGITTAL CONTROL, RIGID POSTERIOR
TLSO, SAGITTAL CONTROL, RIGID POSTERIOR
TLSO, SAGITTAL-CORONAL CONTROL, RIGID PO
TLSO, SAGITTAL-CORONAL CONTROL, RIGID PO
TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR
TLSO, TRIPLANAR CONTROL, HYPEREXTENSION,
TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID

FEE
7037.60
10054.10
11964.50

1265.35
257.81
6.80
183.99
50.00
74.00
79.50
357.00
75.00
130.00
233.00
311.75
322.50
98.00
144.00
330.85
270.00
239.42
778.11
686.57
400.18
400.18
400.18
400.18
280.02
247.07
343.54
303.13
402.39
295.00
900.00

RENTAL
FEE

BR

CODE
L0482
L0484
L0486
L0488
L0490
L0491
L0492
L0621
L0622
L0623
L0624
L0625
L0626
L0627
L0628
L0629
L0630
L0631
L0632
L0633
L0634
L0635
L0636
L0637
L0638
L0639
L0640
L0641
L0642
L0643
L0648
L0649
L0650
L0651
L0700
L0710
L0810
L0820
L0830
L0861
L0970
L0972
L0974
L0976
L0978
L0980
L0982
L0984

DESCRIPTION
TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID
TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID
TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID
TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID
TLSO, SAGITTAL-CORONAL CONTROL, ONE PIEC
TLSO, SAGITTAL-CORONAL CONTROL, MODULAR
TLSO, SAGITTAL-CORONAL CONTROL, MODULAR
SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES
SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES
SACROILIAC ORTHOSIS, PROVIDES PELVIC-SAC
SACROILIAC ORTHOSIS, PROVIDES PELVIC-SAC
LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMB
LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH
LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH
LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVID
LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVID
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH
LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL
CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES
CTLSO, ANTERIOR-POSTERIOR-LATERAL-CONTRO
HALO PROCEDURE, CERVICAL HALO INCORPORA
HALO PROCEDURE, CERVICAL HALO INCORPORA
HALO PROCEDURE, CERVICAL HALO INCORPORA
ADDITION TO HALO PROCEDURE, REPLACEMENT
TLSO, CORSET FRONT
LSO, CORSET FRONT
TLSO, FULL CORSET
LSO, FULL CORSET
AXILLARY CRUTCH EXTENSION
PERITONEAL STRAPS, PAIR
STOCKING SUPPORTER GRIPS, SET OF FOUR (4
PROTECTIVE BODY SOCK EACH

FEE
1442.24
1432.83
1523.40
886.23
249.76
543.13
356.79
72.82
183.65
212.50
212.50
43.27
61.25
322.98
65.92
175.00
127.26
806.64
1150.00
225.31
759.92
765.98
1036.35
844.13
1036.35
844.13
822.21
53.80
283.76
111.80
708.65
197.95
741.59
741.59
1237.50
1480.00
2000.00
1320.00
2225.00
89.42
44.00
40.00
78.00
78.00
68.00
10.00
10.00
21.00

RENTAL
FEE

BR

CODE
L0999
L1000
L1001
L1005
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1300
L1310
L1499
L1600
L1610
L1620
L1630
L1640
L1650
L1652
L1660
L1680
L1685
L1686
L1690
L1700
L1710
L1720
L1730
L1755

DESCRIPTION
ADDITION TO SPINAL ORTHOSIS, NOT OTHERWI
CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS
CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS
TENSION BASED SCOLIOSIS ORTHOSIS AND ACC
ADDITION TO CERVICAL-THORACIC-LUMBAR-SAC
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,
ADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, C
THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO),
ADDITION TO TLSO, (LOW PROFILE), LATERAL
ADDITION TO TLSO, (LOW PROFILE), ANTERIO
ADDITION TO TLSO, (LOW PROFILE), MILWAUK
ADDITION TO TLSO, (LOW PROFILE), LUMBAR
ADDITION TO TLSO, (LOW PROFILE), ANTERIO
ADDITION TO TLSO, (LOW PROFILE), ANTERIO
ADDITION TO TLSO, (LOW PROFILE), ABDOMIN
ADDITION TO TLSO, (LOW PROFILE), RIB GUS
ADDITION TO TLSO, (LOW PROFILE), LATERAL
OTHER SCOLIOSIS PROCEDURE, BODY JACKET M
OTHER SCOLIOSIS PROCEDURE, POST-OPERATI
SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
COMBINATION, BILATERAL, LUMBO-SACRAL, HI
LEGG PERTHES ORTHOSIS, (TORONTO TYPE), C
LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE),
LEGG PERTHES ORTHOSIS, TRILATERAL, (TACH
LEGG PERTHES ORTHOSIS, (SCOTTISH RITE TY
LEGG PERTHES ORTHOSIS, (PATTEN BOTTOM TY

FEE
1375.00
2514.93
30.00
23.00
140.77
40.00
30.00
30.00
45.00
30.00
10.00
85.00
71.51
50.00
181.56
4.60
1000.00
235.00
240.00
362.00
45.00
35.00
35.00
40.00
55.00
40.00
1450.00
1405.00
56.00
27.00
75.00
80.00
456.01
95.00
95.00
70.00
533.50
850.00
750.00
1434.95
900.00
990.00
785.00
750.00
900.00

RENTAL
FEE

BR

CODE
L1810
L1812
L1820
L1830
L1831
L1832
L1833
L1834
L1836
L1840
L1843
L1844
L1845
L1846
L1847
L1848
L1850
L1860
L1900
L1902
L1904
L1906
L1907
L1910
L1920
L1930
L1932
L1940
L1945
L1950
L1951
L1960
L1970
L1971
L1980
L1990
L2000
L2005
L2010
L2020
L2030
L2034
L2035
L2036
L2037
L2038
L2040
L2050

DESCRIPTION
KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREF
KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREF
KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PAD
KNEE ORTHOSIS, IMMOBILIZER, CANVAS LONGI
KNEE ORTHOSIS, LOCKING KNEE JOINT(S), PO
KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (U
KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (U
KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID
KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S),
KNEE ORTHOSIS, DEROTATION, MEDIAL-LATERA
KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND
KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND
KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND
KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND
KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUS
KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUS
KNEE ORTHOSIS, SWEDISH TYPE, PREFABRICAT
KNEE ORTHOSIS, MODIFICATION OF SUPRACOND
ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIF
AFO, ANKLE GAUNTLET, PREFABRICATED, INCL
AFO, MOLDED ANKLE GAUNTLET, CUSTOM-FABRI
ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANK
AFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR
ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE B
ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH
ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MA
AFO, RIGID ANTERIOR TIBIAL SECTION, TOTA
ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MA
ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTE
ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE
ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE
ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANK
ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE
ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MA
ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE
ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE
KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT
KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL,
KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT
KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT
KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC,
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC,
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC,
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC,
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC,
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO

FEE
80.51
71.04
110.00
65.00
208.13
607.55
536.08
595.41
104.84
597.50
634.53
1107.70
693.00
828.15
449.98
397.04
185.00
617.00
185.00
45.00
290.00
75.00
397.93
145.00
228.00
194.00
410.00
410.00
410.00
690.00
593.92
550.00
750.00
331.47
250.00
295.00
650.00
2828.47
750.00
775.00
705.00
1754.51
130.74
1554.50
1554.50
1100.00
75.00
295.00

RENTAL
FEE

BR

CODE
L2060
L2070
L2080
L2090
L2106
L2108
L2112
L2114
L2116
L2126
L2128
L2132
L2134
L2136
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2210
L2220
L2230
L2232
L2250
L2260
L2265
L2270
L2275
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
L2385
L2387
L2390
L2395
L2397
L2405

DESCRIPTION
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,
KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHO
KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHO
KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTUR
KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTUR
KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTUR
ADDITION TO LOWER EXTREMITY FRACTURE ORT
ADDITION TO LOWER EXTREMITY FRACTURE ORT
ADDITION TO LOWER EXTREMITY FRACTURE ORT
ADDITION TO LOWER EXTREMITY FRACTURE ORT
ADDITION TO LOWER EXTREMITY FRACTURE ORT
ADDITION TO LOWER EXTREMITY FRACTURE ORT
ADDITION TO LOWER EXTREMITY FRACTURE ORT
ADDITION TO LOWER EXTREMITY, DORSIFLEXIO
ADDITION TO LOWER EXTREMITY, DORSIFLEXIO
ADDITION TO LOWER EXTREMITY, SPLIT FLAT
ADDITION TO LOWER EXTREMITY ORTHOSIS, RO
ADDITION TO LOWER EXTREMITY, FOOT PLATE
ADDITION TO LOWER EXTREMITY, REINFORCED
ADDITION TO LOWER EXTREMITY, LONG TONGUE
ADDITION TO LOWER EXTREMITY, VARUS/VALG
ADDITION TO LOWER EXTREMITY, VARUS/VALGU
ADDITION TO LOWER EXTREMITY, MOLDED INN
ADDITION TO LOWER EXTREMITY, ABDUCTION
ADDITION TO LOWER EXTREMITY, ABDUCTION
ADDITION TO LOWER EXTREMITY, NON-MOLDED
ADDITION TO LOWER EXTREMITY, LACER MOLDE
ADDITION TO LOWER EXTREMITY, ANTERIOR S
ADDITION TO LOWER EXTREMITY, PRE-TIBIAL
ADDITION TO LOWER EXTREMITY, PROSTHETIC
ADDITION TO LOWER EXTREMITY, EXTENDED S
ADD LOW EXT, PATTEN BOTTOM
ADDITION TO LOWER EXTREMITY, TORSION CO
ADDITION TO LOWER EXTREMITY, TORSION CO
ADDITION TO LOWER EXTREMITY, STRAIGHT K
ADDITION TO LOWER EXTREMITY, POLYCENTRIC
ADDITION TO LOWER EXTREMITY, OFFSET KNE
ADDITION TO LOWER EXTREMITY, OFFSET KNE
ADDITION TO LOWER EXTREMITY ORTHOSIS, SU
ADDITION TO KNEE JOINT, DROP LOCK, EACH

FEE
310.00
65.00
210.00
225.00
427.50
625.00
350.00
375.00
427.50
850.00
1200.00
750.00
675.00
975.00
50.00
35.00
35.00
120.00
338.08
67.00
290.00
43.85
55.50
57.76
30.00
182.50
226.06
85.00
32.00
106.61
270.00
303.63
60.00
208.28
442.81
75.00
255.00
975.00
50.00
130.00
45.00
26.00
32.00
133.44
26.00
26.00
24.00
35.00

RENTAL
FEE

BR

CODE
L2415
L2425
L2430
L2492
L2500
L2510
L2520
L2525
L2526
L2530
L2540
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2755
L2760
L2768
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
L2861
L2999
L3000
L3001
L3002
L3003
L3010
L3020

DESCRIPTION
ADDITION TO KNEE LOCK WITH INTEGRATED RE
ADDITION TO KNEE JOINT, DISC OR DIAL LOC
ADDITION TO KNEE JOINT, RATCHET LOCK FOR
ADDITION TO KNEE JOINT, LIFT LOOP FOR DR
ADDITION TO LOWER EXTREMITY, THIGH/WEIGH
ADDITION TO LOWER EXTREMITY, THIGH/WEIGH
ADDITION TO LOWER EXTREMITY, THIGH/WEIG
ADDITION TO LOWER EXTREMITY, THIGH/WEIGH
ADDITION TO LOWER EXTREMITY, THIGH/WEIGH
ADDITION TO LOWER EXTREMITY, THIGH-WEIG
ADDITION TO LOWER EXTREMITY, THIGH/WEIG
ADDITION TO LOWER EXTREMITY, THIGH/WEIG
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC CONT
ADDITION TO LOWER EXTREMITY, PELVIC AND
ADDITION TO LOWER EXTREMITY, THORACIC CO
ADDITION TO LOWER EXTREMITY, THORACIC CO
ADDITION TO LOWER EXTREMITY, THORACIC CO
ADDITION TO LOWER EXTREMITY ORTHOSIS, PL
ADDITION TO LOWER EXTREMITY ORTHOSIS, HI
ADDITION TO LOWER EXTREMITY ORTHOSIS, EX
ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER
ADDITION TO LOWER EXTREMITY ORTHOSIS, NO
ADDITION TO LOWER EXTREMITY ORTHOSIS, DR
ADDITION TO LOWER EXTREMITY ORTHOSIS, KN
ADDITION TO LOWER EXTREMITY ORTHOSIS, KN
ADDITION TO LOWER EXTREMITY ORTHOSIS, KN
ADDITION TO LOWER EXTREMITY ORTHOSIS, SO
ADDITION TO LOWER EXTREMITY ORTHOSIS, SO
ADDITION TO LOWER EXTREMITY ORTHOSIS, TI
ADDITION TO LOWER EXTREMITY ORTHOSIS, FE
ADDITION TO LOWER EXTREMITY JOINT, KNEE
LOWER EXTREMITY ORTHOSES, NOT OTHERWISE
FOOT, INSERT, REMOVABLE, MOLDED TO PATIE
FOOT, INSERT, REMOVABLE, MOLDED TO PATIE
FOOT, INSERT, REMOVABLE, MOLDED TO PATIE
FOOT, INSERT, REMOVABLE, MOLDED TO PATIE
FOOT, INSERT, REMOVABLE, MOLDED TO PATIE
FOOT, INSERT, REMOVABLE, MOLDED TO PATIE

FEE

RENTAL
FEE

BR

45.00
122.50
122.50
45.00
168.00
715.09
450.00
1186.65
579.32
250.00
264.00
295.20
155.00
350.00
85.00
239.70
301.53
140.00
250.00
1110.00
1110.00
255.07
378.98
27.50
118.00
133.00
126.00
83.22
60.00
63.21
92.14
60.00
24.50
53.50
75.00
30.00
84.37
97.84
30.00
40.00
BR SC
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)

CODE
L3030
L3040
L3050
L3060
L3070
L3080
L3090
L3100
L3140
L3150
L3160
L3170
L3201
L3202
L3203
L3204
L3206
L3207
L3208
L3209
L3211
L3212
L3213
L3214
L3215
L3216
L3217
L3219
L3221
L3222
L3224
L3225
L3230
L3250
L3252
L3253
L3254
L3255
L3257
L3260
L3265
L3300
L3310
L3320
L3330
L3332
L3334
L3340

DESCRIPTION
FOOT, INSERT, REMOVABLE, FORMED TO PATIE
FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED
FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED
FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED
FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACH
FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACH
FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACH
HALLUS-VALGUS NIGHT DYNAMIC SPLINT
FOOT, ABDUCTION ROTATION BAR, INCLUDING
FOOT, ABDUCTION ROTATATION BAR, WITHOUT
FOOT, ADJUSTABLE SHOE-STYLED POSITIONING
FOOT, PLASTIC, SILICONE OR EQUAL, HEEL S
ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR O
ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR O
ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR O
ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR
ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR
ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR
SURGICAL BOOT EACH INFANT
SURGICAL BOOT EACH CHILD
SURGICAL BOOT EACH JUNIOR
BENESCH BOOT PAIR INFANT
BENESCH BOOT PAIR CHILD
BENESCH BOOT PAIR JUNIOR
ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD
ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH
ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTO
ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD,
ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH IN
ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP,
ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFOR
ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD,
ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH
ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE,
FOOT, SHOE MOLDED TO PATIENT MODEL, PLAS
FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR
NON-STANDARD SIZE OR WIDTH
NON-STANDARD SIZE OR LENGTH
ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE F
SURGICAL BOOT/SHOE, EACH
PLASTAZOTE SANDAL EACH
LIFT, ELEVATION, HEEL, TAPERED TO METATA
LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE
LIFT, ELEVATION, HEEL AND SOLE, CORK, PE
LIFT, ELEVATION, METAL EXTENSION (SKATE)
LIFT, ELEVATION, INSIDE SHOE, TAPERED, U
LIFT, ELEVATION, HEEL, PER INCH
HEEL WEDGE, SACH

RENTAL
BR
FEE
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)

FEE

CODE
L3350
L3360
L3370
L3380
L3390
L3400
L3410
L3420
L3430
L3440
L3450
L3455
L3460
L3465
L3470
L3480
L3485
L3540
L3570
L3580
L3600
L3610
L3620
L3630
L3640
L3649
L3650
L3660
L3670
L3671
L3674
L3675
L3677
L3702
L3710
L3720
L3730
L3740
L3760
L3762
L3763
L3764
L3765
L3766
L3806
L3807
L3808
L3809

DESCRIPTION
HEEL WEDGE
SOLE WEDGE, OUTSIDE SOLE
SOLE WEDGE, BETWEEN SOLE
CLUBFOOT WEDGE
OUTFLARE WEDGE
METATARSAL BAR WEDGE, ROCKER
METATARSAL BAR WEDGE, BTWN SOL
FULL SOLE AND HEEL WEDGE, BETWEEN SOLE
HEEL COUNTER PLASTIC REINFORCED
HEEL, COUNTER, LEATHER REINFORCED
HEEL, SACH CUSHION TYPE
HEEL, NEW LEATHER, STANDARD
HEEL, NEW RUBBER, STANDARD
HEEL, THOMAS WITH WEDGE
HEEL, THOMAS EXTENDED TO BALL
HEEL, PAD & DEPRESSION FOR SPUR
HEEL, PAD, REMOVABLE FOR SPUR
ORTHOPEDIC SHOE ADDITION, SOLE, FULL
ORTHOPEDIC SHOE ADDITION, SPECIAL EXTENS
ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP
TRANSFER OF AN ORTHOSIS FROM ONE SHOE T
TRANSFER OF AN ORTHOSIS FROM ONE SHOE T
TRANSFER OF AN ORTHOSIS FROM ONE SHOE T
TRANSFER OF AN ORTHOSIS FROM ONE SHOE T
TRANSFER OF AN ORTHOSIS FROM ONE SHOE T
ORTHOPEDIC SHOE, MODIFICATION, ADDITION
SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIG
SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIG
SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR (C
SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN
SHOULDER ORTHOSIS, ABDUCTION POSITIONING
SHOULDER ORTHOSIS, VEST TYPE ABDUCTION R
SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN
ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCL
ELBOW ORTHOSIS, ELASTIC WITH METAL JOINT
ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FORE
ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FORE
ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FORE
ELBOW ORTHOSIS, WITH ADJUSTABLE POSITION
ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, I
ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOU
ELBOW WRIST HAND ORTHOSIS, INCLUDES ONE
ELBOW WRIST HAND FINGER ORTHOSIS, RIGID,
ELBOW WRIST HAND FINGER ORTHOSIS, INCLUD
WRIST HAND FINGER ORTHOSIS, INCLUDES ONE
WRIST HAND FINGER ORTHOSIS, WITHOUT JOIN
WRIST HAND FINGER ORTHOSIS, RIGID WITHOU
WRIST HAND FINGER ORTHOSIS, WITHOUT JOIN

RENTAL
BR
FEE
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
Fee as per NYCRR Title 12 442.2 (a)(1)(2)
40.00
40.00
251.34
690.23
896.92
141.14

FEE

221.18
77.00
721.79
902.00
1091.24
251.34
69.20
590.25
742.84
982.19
1090.98
347.95
178.04
310.80
157.10

CODE
L3891
L3900
L3901
L3904
L3905
L3906
L3908
L3912
L3913
L3915
L3916
L3917
L3918
L3919
L3921
L3923
L3924
L3925
L3927
L3929
L3930
L3931
L3933
L3935
L3960
L3961
L3962
L3967
L3971
L3973
L3975
L3976
L3977
L3978
L3980
L3982
L3984
L3995
L3999
L4000
L4002
L4010
L4020
L4030
L4040
L4045
L4050
L4055

DESCRIPTION
ADDITION TO UPPER EXTREMITY JOINT, WRIST
WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEX
WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEX
WRIST HAND FINGER ORTHOSIS, EXTERNAL POW
WRIST HAND ORTHOSIS, INCLUDES ONE OR MOR
WRIST HAND ORTHOSIS, WITHOUT JOINTS, MAY
WRIST HAND ORTHOSIS, WRIST EXTENSION CON
HAND FINGER ORTHOSIS, FLEXION GLOVE WITH
HAND FINGER ORTHOSIS, WITHOUT JOINTS, MA
WRIST HAND ORTHOSIS, INCLUDES ONE OR MOR
WRIST HAND ORTHOSIS, INCLUDES ONE OR MOR
HAND ORTHOSIS, METACARPAL FRACTURE ORTHO
HAND ORTHOSIS, METACARPAL FRACTURE ORTHO
HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLU
HAND FINGER ORTHOSIS, INCLUDES ONE OR MO
HAND FINGER ORTHOSIS, WITHOUT JOINTS, MA
HAND FINGER ORTHOSIS, WITHOUT JOINTS, MA
FINGER ORTHOSIS, PROXIMAL INTERPHALANGEA
FINGER ORTHOSIS, PROXIMAL INTERPHALANGEA
HAND FINGER ORTHOSIS, INCLUDES ONE OR MO
HAND FINGER ORTHOSIS, INCLUDES ONE OR MO
WRIST HAND FINGER ORTHOSIS, INCLUDES ONE
FINGER ORTHOSIS, WITHOUT JOINTS, MAY INC
FINGER ORTHOSIS, NONTORSION JOINT, MAY I
SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDU
SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOU
SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDU
SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDU
SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOU
SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDU
SHOULDER ELBOW WRIST HAND FINGER ORTHOSI
SHOULDER ELBOW WRIST HAND FINGER ORTHOSI
SHOULDER ELBOW WRIST HAND FINGER ORTHOSI
SHOULDER ELBOW WRIST HAND FINGER ORTHOSI
UPPER EXTREMITY FRACTURE ORTHOSIS, HUMER
UPPER EXTREMITY FRACTURE ORTHOSIS, RADIU
UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST
ADDITION TO UPPER EXTREMITY ORTHOSIS, SO
UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECI
REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLS
REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDE
REPLACE TRILATERAL SOCKET BRIM
REPLACE QUADRILATERAL SOCKET BRIM, MOLDE
REPLACE QUADRILATERAL SOCKET BRIM, CUSTO
REPLACE MOLDED THIGH LACER, FOR CUSTOM F
REPLACE NON-MOLDED THIGH LACER, FOR CUST
REPLACE MOLDED CALF LACER, FOR CUSTOM FA
REPLACE NON-MOLDED CALF LACER, FOR CUSTO

FEE

RENTAL
FEE

BR

585.00
1471.49
759.66
232.50
47.50
45.00
207.47
407.17
333.36
75.23
66.38
207.47
246.06
63.80
56.30
31.83
28.10
57.33
50.59
72.55
163.44
169.22
372.50
1286.96
499.12
1519.48
1442.33
1519.48
1286.96
1286.96
1442.33
1519.48
292.56
411.96
260.00
30.00
BR SC
650.00
20.00
500.00
615.00
455.00
408.23
185.00
590.00
185.00

CODE
L4060
L4070
L4080
L4090
L4100
L4110
L4130
L4205
L4210
L4396
L4397
L4398
L5000
L5010
L5020
L5050
L5100
L5105
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5312
L5321
L5331
L5341
L5400
L5410
L5420
L5430
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580

DESCRIPTION
REPLACE HIGH ROLL CUFF
REPLACE PROXIMAL AND DISTAL UPRIGHT FOR
REPLACE METAL BANDS KAFO, PROXIMAL THIGH
REPLACE METAL BANDS KAFO-AFO, CALF OR DI
REPLACE LEATHER CUFF KAFO, PROXIMAL THIG
REPLACE LEATHER CUFF KAFO-AFO, CALF OR D
REPLACE PRETIBIAL SHELL
REPAIR OF ORTHOTIC DEVICE, LABOR COMPONE
REPAIR OF ORTHOTIC DEVICE, REPAIR OR REP
STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDE
STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDE
DROP FOOT SPLINT, RECUMENT POSITIONING DEVICE
PARTIAL FOOT, SHOE INSERT WITH LONGITUDI
PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGH
PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBE
ANKLE, SYMES, MOLDED SOCKET, SACH FOOT
BELOW KNEE, MOLDED SOCKET, SHIN, SACH FO
BELOW KNEE, PLASTIC SOCKET, JOINTS AND T
KNEE DISARTICULATION (OR THROUGH KNEE),
KNEE DISARTICULATION (OR THROUGH KNEE),
ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS C
ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JO
ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JO
ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL D
HIP DISARTICULATION, CANADIAN TYPE; MOLD
HIP DISARTICULATION, TILT TABLE TYPE; MO
HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SO
BELOW KNEE, MOLDED SOCKET, SHIN, SACH FO
KNEE DISARTICULATION (OR THROUGH KNEE),
ABOVE KNEE, MOLDED SOCKET, OPEN END, SAC
HIP DISARTICULATION, CANADIAN TYPE, MOLD
HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SO
IMMEDIATE POST SURGICAL OR EARLY FITTING
IMMEDIATE POST SURGICAL OR EARLY FITTING
IMMEDIATE POST SURGICAL OR EARLY FITTING
IMMEDIATE POST SURGICAL OR EARLY FITTING
IMMEDIATE POST SURGICAL OR EARLY FITTING
IMMEDIATE POST SURGICAL OR EARLY FITTING
INITIAL, BELOW KNEE 'PTB' TYPE SOCKET, N
INITIAL, ABOVE KNEE - KNEE DISARTICULATI
PREPARATORY, BELOW KNEE 'PTB' TYPE SOC
PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKE
PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKE
PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKE
PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKE
PREPARATORY, ABOVE KNEE- KNEE DISARTICUL
PREPARATORY, ABOVE KNEE - KNEE DISARTICU
PREPARATORY, ABOVE KNEE - KNEE DISARTICU

FEE
115.00
101.00
52.50
52.50
75.00
60.00
188.00
18.00
35.00
151.70
115.83
69.85
300.00
871.07
1019.50
1500.00
1635.00
2850.00
2000.00
2235.00
2000.00
2630.00
2236.62
2150.00
3135.00
3000.00
3500.00
1300.00
1825.00
2010.00
2531.00
2816.10
705.00
305.00
900.00
305.00
408.38
491.35
633.50
878.50
1180.00
1250.00
1767.00
1235.00
1630.93
1584.00
1700.00
1948.00

RENTAL
FEE

BR

CODE
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5618
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654
L5655
L5656
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673

DESCRIPTION
PREPARATORY, ABOVE KNEE - KNEE DISARTICU
PREPARATORY, ABOVE KNEE - KNEE DISARTICU
PREPARATORY, HIP DISARTICULATION-HEMIPEL
PREPARATORY, HIP DISARTICULATION-HEMIPEL
ADD TO LOWER EXT,ABOVE KNEE HY
ADDITION TO LOWER EXTREMITY, ENDOSKELETA
ADDITION TO LOWER EXTREMITY, ENDOSKELETA
ADDITION TO LOWER EXTREMITY, EXOSKELETAL
ADDITION TO LOWER EXTREMITY, TEST SOCKET
ADDITION TO LOWER EXTREMITY, TEST SOCKET
ADDITION TO LOWER EXTREMITY, TEST SOCKET
ADDITION TO LOWER EXTREMITY, TEST SOCKET
ADDITION TO LOWER EXTREMITY, TEST SOCKET
ADDITION TO LOWER EXTREMITY, TEST SOCKET
ADDITION TO LOWER EXTREMITY, BELOW KNEE,
ADDITION TO LOWER EXTREMITY, SYMES TYPE,
ADDITION TO LOWER EXTREMITY, ABOVE KNEE
ADDITION TO LOWER EXTREMITY, SYMES TYPE,
ADDITION TO LOWER EXTREMITY, SYMES TYPE,
ADDITION TO LOWER EXTREMITY, SYMES TYPE
ADDITION TO LOWER EXTREMITY, BELOW KNEE,
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE,
ADDITION TO LOWER EXTREMITY, KNEE DISAR
ADDITION TO LOWER EXTREMITY, ABOVE KNEE
ADDITION TO LOWER EXTREMITY, HIP DISART
ADDITION TO LOWER EXTREMITY, ABOVE KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE,
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
ADDITION TO LOWER EXTREMITY, ISCHIAL CO
ADDITIONS TO LOWER EXTREMITY, TOTAL CONT
ADDITION TO LOWER EXTREMITY, ABOVE KNEE
ADDITION TO LOWER EXTREMITY, SUCTION SU
ADDITION TO LOWER EXTREMITY, KNEE DISAR
ADDITION TO LOWER EXTREMITY, SOCKET INS
ADDITION TO LOWER EXTREMITY, SOCKET INS
ADDITION TO LOWER EXTREMITY, SOCKET INS
ADDITION TO LOWER EXTREMITY, SOCKET INS
ADDITION TO LOWER EXTREMITY, SOCKET INS
ADDITION TO LOWER EXTREMITY, SOCKET INS
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE/

FEE
1518.00
2150.00
3300.00
3895.00
1650.00
1050.00
1525.00
1492.71
222.00
222.00
264.00
264.00
280.00
375.00
300.00
250.00
450.00
160.00
350.00
306.13
332.12
465.00
600.00
675.00
590.00
725.00
475.00
425.00
494.50
585.00
528.12
1000.00
555.00
725.00
96.00
300.00
210.00
210.00
250.00
250.00
450.00
350.00
35.00
65.00
180.00
448.21
100.00
413.48

RENTAL
FEE

BR

CODE
L5676
L5677
L5678
L5679
L5680
L5681
L5682
L5683
L5684
L5685
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5700
L5701
L5702
L5703
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5722
L5724
L5726
L5728
L5780
L5781
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818

DESCRIPTION
ADDITIONS TO LOWER EXTREMITY, BELOW KNEE
ADDITIONS TO LOWER EXTREMITY, BELOW KNEE
ADDITIONS TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE/
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE/
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE/
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY PROSTHESIS,
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE
ADDITION TO LOWER EXTREMITY, ABOVE KNEE
ADDITION TO LOWER EXTREMITY, ABOVE KNEE
ADDITION TO LOWER EXTREMITY, ABOVE KNEE,
ADDITION TO LOWER EXTREMITY, ABOVE KNEE
ADDITION TO LOWER EXTREMITY, ABOVE KNEE
ADDITION TO LOWER EXTREMITY, ABOVE KNEE
ALL LOWER EXTREMITY PROSTHESES, SHOULDER
REPLACEMENT, SOCKET, BELOW KNEE, MOLDED
REPLACEMENT, SOCKET, ABOVE KNEE/KNEE DIS
REPLACEMENT, SOCKET, HIP DISARTICULATION
ANKLE, SYMES, MOLDED TO PATIENT MODEL, S
CUSTOM SHAPED PROTECTIVE COVER, BELOW KN
CUSTOM SHAPED PROTECTIVE COVER, ABOVE KN
CUSTOM SHAPED PROTECTIVE COVER, KNEE DIS
CUSTOM SHAPED PROTECTIVE COVER, HIP DISA
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,
ADDITON TO LOWER LIMB, PROSTHESIS VACUUM
ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE
ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE
ADDITION, EXOSKELETAL SYSTEM, HIP DISART
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,

FEE
275.00
125.00
25.00
398.59
285.00
729.24
510.00
729.24
25.00
95.53
54.00
50.00
60.00
75.00
85.00
99.00
135.00
55.00
80.00
125.00
1572.31
2000.00
2700.00
1998.19
475.00
650.00
675.00
923.00
240.00
330.00
293.00
200.00
280.00
531.00
1170.00
1297.50
1405.00
598.00
3689.88
254.00
375.00
575.00
250.00
325.00
275.00
2761.26
644.10
779.49

RENTAL
FEE

BR

CODE
L5822
L5824
L5826
L5828
L5830
L5840
L5845
L5850
L5855
L5856
L5857
L5858
L5910
L5920
L5925
L5930
L5940
L5950
L5960
L5962
L5964
L5966
L5968
L5970
L5971
L5972
L5973
L5974
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L5987
L5988
L5990
L5999
L6000
L6010
L6020
L6026
L6050
L6055

DESCRIPTION
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM,
ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KN
ADDITION, ENDOSKELETAL SYSTEM, HIP DISAR
ADDITION TO LOWER EXTREMITY PROSTHESIS,
ADDITION TO LOWER EXTREMITY PROSTHESIS,
ADDITION TO LOWER EXTREMITY PROSTHESIS,
ADDITION, ENDOSKELETAL SYSTEM, BELOW KN
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNE
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNE
ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTI
ADDITION, ENDOSKELETAL SYSTEM, BELOW KN
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KN
ADDITION, ENDOSKELETAL SYSTEM, HIP DISA
ADDITION, ENDOSKELETAL SYSTEM, BELOW KNE
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNE
ADDITION, ENDOSKELETAL SYSTEM, HIP DISAR
ADDITION TO LOWER LIMB PROSTHESIS, MULTI
ALL LOWER EXTREMITY PROSTHESES, FOOT, EX
ALL LOWER EXTREMITY PROSTHESIS, SOLID AN
ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE
ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPRO
ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE
ALL LOWER EXTREMITY PROSTHESIS, COMBINAT
ALL LOWER EXTREMITY PROSTHESES, ENERGY S
ALL LOWER EXTREMITY PROSTHESES, FOOT, MU
ALL LOWER EXTREMITY PROSTHESIS, MULTI-AX
ALL LOWER EXTREMITY PROSTHESES, FLEX FOO
ALL LOWER EXTREMITY PROSTHESES, FLEX-WAL
ALL EXOSKELETAL LOWER EXTREMITY PROSTHES
ALL ENDOSKELETAL LOWER EXTREMITY PROSTHE
ALL ENDOSKELETAL LOWER EXTREMITY PROSTHE
ALL LOWER EXTREMITY PROSTHESES, MULTI-AX
ALL LOWER EXTREMITY PROSTHESIS, SHANK FO
ADDITION TO LOWER LIMB PROSTHESIS, VERTI
ADDITION TO LOWER EXTREMITY PROSTHESIS,
LOWER EXTREMITY PROSTHESIS, NOT OTHERWIS
PARTIAL HAND, ROBIN-AIDS, THUMB REMAININ
PARTIAL HAND, ROBIN-AIDS, LITTLE AND/OR
PARTIAL HAND, ROBIN-AIDS, NO FINGER REMA
TRANSCARPAL/METACARPAL OR PARTIAL HAND D
WRIST DISARTICULATION, MOLDED SOCKET, FL
WRIST DISARTICULATION, MOLDED SOCKET WIT

FEE
1902.62
1710.93
2809.50
3020.00
1625.00
3195.78
1332.63
60.00
100.00

250.00
250.00
100.00
2552.81
475.00
650.00
950.00
450.00
600.00
700.00
3214.56
145.00
174.46
175.00
110.00
410.09
475.00
150.00
2056.06
3500.00
1850.00
275.00
456.86
214.16
275.00
5348.57
1755.00
1285.48
1025.00
1000.00
1050.00
5760.19
1480.00
1847.00

RENTAL
FEE

BR

CODE
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6386
L6388
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6611
L6615
L6616
L6620
L6621
L6623
L6624
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6638
L6640

DESCRIPTION
BELOW ELBOW, MOLDED SOCKET, FLEXIBLE ELB
BELOW ELBOW, MOLDED SOCKET, (MUENSTER OR
BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SO
BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SO
ELBOW DISARTICULATION, MOLDED SOCKET, OU
ELBOW DISARTICULATION, MOLDED SOCKET WIT
ABOVE ELBOW, MOLDED DOUBLE WALL SOCKET,
SHOULDER DISARTICULATION, MOLDED SOCKET,
SHOULDER DISARTICULATION, PASSIVE RESTOR
SHOULDER DISARTICULATION, PASSIVE RESTOR
INTERSCAPULAR THORACIC, MOLDED SOCKET, S
INTERSCAPULAR THORACIC, PASSIVE RESTORAT
INTERSCAPULAR THORACIC, PASSIVE RESTORAT
IMMEDIATE POST SURGICAL OR EARLY FITTING
IMMEDIATE POST SURGICAL OR EARLY FITTING
IMMEDIATE POST SURGICAL OR EARLY FITTING
IMMEDIATE POST SURGICAL OR EARLY FITTING
IMMEDIATE POST SURGICAL OR EARLY FITTING
BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL
ELBOW DISARTICULATION, MOLDED SOCKET, EN
ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL
SHOULDER DISARTICULATION, MOLDED SOCKET,
INTERSCAPULAR THORACIC, MOLDED SOCKET, E
PREPARATORY, WRIST DISARTICULATION OR BE
PREPARATORY, WRIST DISARTICULATION OR BE
PREPARATORY, ELBOW DISARTICULATION OR AB
PREPARATORY, ELBOW DISARTICULATION OR AB
PREPARATORY, SHOULDER DISARTICULATION OR
PREPARATORY, SHOULDER DISARTICULATION OR
UPPER EXTREMITY ADDITIONS, POLYCENTRIC H
UPPER EXTREMITY ADDITIONS, SINGLE PIVOT
UPPER EXTREMITY ADDITIONS, FLEXIBLE META
ADDITION TO UPPER EXTREMITY PROSTHESIS,
UPPER EXTREMITY ADDITION, DISCONNECT LO
UPPER EXTREMITY ADDITION, ADDITIONAL DIS
UPPER EXTREMITY ADDITION, FLEXION/EXTENS
UPPER EXTREMITY PROSTHESIS ADDITION, FLE
UPPER EXTREMITY ADDITION, SPRING ASSIST
UPPER EXTREMITY ADDITION, FLEXION/EXTENS
UPPER EXTREMITY ADDITION, ROTATION WRIS
UPPER EXTREMITY ADDITION, QUICK DISCONN
UPPER EXTREMITY ADDITION, QUICK DISCONN
UPPER EXTREMITY ADDITION, STAINLESS STE
UPPER EXTREMITY ADDITION, LATEX SUSPENS
UPPER EXTREMITY ADDITION, LIFT ASSIST F
UPPER EXTREMITY ADDITION, NUDGE CONTROL
UPPER EXTREMITY ADDITION TO PROSTHESIS,
UPPER EXTREMITY ADDITIONS, SHOULDER ABDU

FEE
1890.00
2080.00
2290.00
2415.00
1532.50
2300.00
2150.00
3000.00
1950.00
850.00
4025.00
2870.12
1875.00
705.00
900.00
1200.00
305.00
396.14
1850.00
2200.00
2000.00
2390.00
3529.98
1070.00
918.00
1350.00
1200.00
1800.00
1650.00
194.00
175.00
90.00
347.22
105.50
37.00
205.00
1928.92
274.00
3176.01
250.00
75.00
125.00
194.20
42.00
115.00
177.50
1771.93
300.00

RENTAL
FEE

BR

CODE
L6641
L6642
L6645
L6646
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6677
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6693
L6694
L6695
L6696
L6697
L6698
L6703
L6706
L6707
L6708
L6709
L6711
L6712
L6713
L6714
L6721
L6722
L6805
L6810
L6881
L6882
L6883
L6884
L6885
L6890

DESCRIPTION
UPPER EXTREMITY ADDITION, EXCURSION AMP
UPPER EXTREMITY ADDITION, EXCURSION AMP
UPPER EXTREMITY ADDITION, SHOULDER FLEX
UPPER EXTREMITY ADDITION, SHOULDER JOINT
UPPER EXTREMITY ADDITION, SHOULDER UNIV
UPPER EXTREMITY ADDITION, STANDARD CONT
UPPER EXTREMITY ADDITION, HEAVY DUTY CO
UPPER EXTREMITY ADDITION, TEFLON, OR EQ
UPPER EXTREMITY ADDITION, HOOK TO HAND,
UPPER EXTREMITY ADDITION, HARNESS, CHES
UPPER EXTREMITY ADDITION, HARNESS, (E.G.
UPPER EXTREMITY ADDITION, HARNESS, (E.G.
UPPER EXTREMITY ADDITION, HARNESS, TRIPL
UPPER EXTREMITY ADDITION, TEST SOCKET,
UPPER EXTREMITY ADDITION, TEST SOCKET,
UPPER EXTREMITY ADDITION, TEST SOCKET,
UP EXT ADD, SUCTION SOCKET
UPPER EXTREMITY ADDITION, FRAME TYPE SOC
UPPER EXTREMITY ADDITION, FRAME TYPE SOC
UPPER EXTREMITY ADDITION, FRAME TYPE SO
UPPER EXTREMITY ADDITION, FRAME TYPE SO
UPPER EXTREMITY ADDITION, REMOVABLE INS
UPPER EXTREMITY ADDITION, SILICONE GEL I
UPPER EXTREMITY ADDITION, LOCKING ELBOW,
ADDITION TO UPPER EXTREMITY PROSTHESIS,
ADDITION TO UPPER EXTREMITY PROSTHESIS,
ADDITION TO UPPER EXTREMITY PROSTHESIS,
ADDITION TO UPPER EXTREMITY PROSTHESIS,
ADDITION TO UPPER EXTREMITY PROSTHESIS,
TERMINAL DEVICE, PASSIVE HAND/MITT, ANY
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUN
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUN
TERMINAL DEVICE, HAND, MECHANICAL, VOLUN
TERMINAL DEVICE, HAND, MECHANICAL, VOLUN
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUN
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUN
TERMINAL DEVICE, HAND, MECHANICAL, VOLUN
TERMINAL DEVICE, HAND, MECHANICAL, VOLUN
TERMINAL DEVICE, HOOK OR HAND, HEAVY DUT
TERMINAL DEVICE, HOOK OR HAND, HEAVY DUT
ADDITION TO TERMINAL DEVICE, MODIFIER WR
ADDITION TO TERMINAL DEVICE, PRECISION P
AUTOMATIC GRASP FEATURE, ADDITION TO UPP
MICROPROCESSOR CONTROL FEATURE, ADDITION
REPLACEMENT SOCKET, BELOW ELBOW/WRIST DI
REPLACEMENT SOCKET, ABOVE ELBOW/ELBOW DI
REPLACEMENT SOCKET, SHOULDER DISARTICULA
ADDITION TO UPPER EXTREMITY PROSTHESIS,

FEE
65.00
261.25
290.80
2234.80
300.00
49.00
64.00
35.00
25.00
133.00
90.00
130.00
250.16
210.00
210.00
330.00
585.00
425.00
491.19
725.00
725.00
210.00
450.00
2511.38
450.00
450.00

177.50
372.35
250.00
892.92
612.87
678.50

295.00
115.00
2896.79
2197.34
1817.59
1998.82
2736.19
185.25

RENTAL
FEE

BR

CODE
L6895
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7007
L7008
L7009
L7040
L7045
L7170
L7180
L7181
L7185
L7186
L7190
L7191
L7259
L7360
L7362
L7364
L7366
L7367
L7368
L7499
L7510
L7520
L7900
L8000
L8001
L8002
L8010
L8020
L8030
L8031
L8035

DESCRIPTION
ADDITION TO UPPER EXTREMITY PROSTHESIS,
HAND RESTORATION (CASTS, SHADING AND MEA
HAND RESTORATION (CASTS, SHADING AND MEA
HAND RESTORATION (CASTS, SHADING AND MEA
HAND RESTORATION (SHADING, AND MEASUREME
WRIST DISARTICULATION, EXTERNAL POWER, S
WRIST DISARTICULATION, EXTERNAL POWER, S
BELOW ELBOW, EXTERNAL POWER, SELF-SUSPEN
BELOW ELBOW, EXTERNAL POWER, SELF-SUSPEN
ELBOW DISARTICULATION, EXTERNAL POWER, M
ELBOW DISARTICULATION, EXTERNAL POWER, M
ABOVE ELBOW, EXTERNAL POWER, MOLDED INNE
ABOVE ELBOW, EXTERNAL POWER, MOLDED INNE
SHOULDER DISARTICULATION, EXTERNAL POWER
SHOULDER DISARTICULATION, EXTERNAL POWER
INTERSCAPULAR-THORACIC, EXTERNAL POWER,
INTERSCAPULAR-THORACIC, EXTERNAL POWER,
ELECTRIC HAND, SWITCH OR MYOELECTRIC CON
ELECTRIC HAND, SWITCH OR MYOELECTRIC, CO
ELECTRIC HOOK, SWITCH OR MYOELECTRIC CON
PREHENSILE ACTUATOR, SWITCH CONTROLLED
ELECTRIC HOOK, SWITCH OR MYOELECTRIC ONT
ELECTRONIC ELBOW, HOSMER OR EQUAL, SWITC
ELECTRONIC ELBOW, MICROPROCESSOR SEQUENT
ELECTRONIC ELBOW, MICROPROCESSOR SIMULTA
ELECTRONIC ELBOW, ADOLESCENT, VARIETY VI
ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE
ELECTRONIC ELBOW, ADOLESCENT, VARIETY VI
ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE
ELECTRONIC WIRST ROTATOR, ANY TYPE
SIX VOLT BATTERY, EACH
BATTERY CHARGER, SIX VOLT, EACH
TWELVE VOLT BATTERY, EACH
BATTERY CHARGER, TWELVE VOLT, EACH
LITHIUM ION BATTERY, RECHARGEABLE REPLACEMENT
LITHIUM 10N BATTERY CHARGER
UPPER EXTREMITY PROSTHESIS, NOT OTHERWIS
REPAIR OF PROSTHETIC DEVICE, REPAIR OR R
REPAIR PROSTHETIC DEVICE, LABOR COMPONEN
MALE VACUUM ERECTION SYSTEM
BREAST PROSTHESIS, MASTECTOMY BRA
BREAST PROSTHESIS, MASTECTOMY BRA, WITH
BREAST PROSTHESIS, MASTECTOMY BRA, WITH
BREAST PROSTHESIS, MASTECTOMY SLEEVE
BREAST PROSTHESIS, MASTECTOMY FORM
BREAST PROSTHESIS, SILICONE OR EQUAL, WI
BREAST PROSTHESIS, SILICONE OR EQUAL, WI
CUSTOM BREAST PROSTHESIS, POST MASTECTOM

FEE
278.00
1050.00
1050.00
1050.00
278.00

3367.16
5279.07
3195.10

6810.00

222.50
211.00
383.48
516.56
275.86
357.61
35.00
18.00
183.75
31.22
93.74
123.74
49.22
180.63
180.63
180.63
180.63

RENTAL
FEE

BR

CODE

DESCRIPTION

FEE

L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8417
L8420
L8430
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8499
L8500
L8501
L8505
L8507
L8510
L8511
L8512
L8513
L8514
L8515
L8621
L9900
S1040
S8100
S8101
S8185
S8189
S8265
S8270
S8421
S8424
S8427
S8428
S8460
S8999
T4521
T4522
T4523
T4524
T4529

TRUSS, SINGLE WITH STANDARD PAD


TRUSS, DOUBLE WITH STANDARD PADS
TRUSS, ADDITION TO STANDARD PAD, WATER P
TRUSS, ADDITION TO STANDARD PAD, SCROTAL
PROSTHETIC SHEATH, BELOW KNEE, EACH
PROSTHETIC SHEATH, ABOVE KNEE, EACH
PROSTHETIC SHEATH, UPPER LIMB, EACH
PROSTHETIC SHEATH/SOCK, INCLUDING A GEL
PROSTHETIC SOCK, MULTIPLE PLY, BELOW KNE
PROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNE
PROSTHETIC SOCK, MULTIPLE PLY, UPPER LI
PROSTHETIC SHRINKER, BELOW KNEE, EACH
PROSTHETIC SHRINKER, ABOVE KNEE, EACH
PROSTHETIC SHRINKER, UPPER LIMB, EACH
PROSTHETIC SOCK, SINGLE PLY, FITTING, BE
PROSTHETIC SOCK, SINGLE PLY, FITTING, AB
PROSTHETIC SOCK, SINGLE PLY, FITTING, UP
UNLISTED PROCEDURE FOR MISCELLANEOUS PRO
ARTIFICAL LARYNX ANY TYPE
TRACHEOSTOMY SPEAKING VALVE
ARTIFICIAL LARYNX REPLACEMENT BATTERY /
TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, PAT
VOICE AMPLIFIER
INSERT FOR INDWELLING TRACHEOESOPHAGEAL
GELATIN CAPSULES OR EQUIVALENT, FOR USE
CLEANING DEVICE USED WITH TRACHEOESOPHAG
TRACHEOESOPHAGEAL PUNCTURE DILATOR, REPL
GELATIN CAPSULE, APPLICATION DEVICE FOR
ZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE
ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSOR
CRANIAL REMOLDING ORTHOSIS, PEDIATRIC, R
HOLDING CHAMBER OR SPACER FOR USE WITH A
HOLDING CHAMBER OR SPACER FOR USE WITH A
FLUTTER DEVICE
TRACHEOSTOMY SUPPLY, NOT OTHERWISE CLASS
HABERMAN FEEDER FOR CLEFT LIP/PALATE
ENURESIS ALARM, USING AUDITORY BUZZER AN
GRADIENT PRESSURE AID (SLEEVE AND GLOVE
GRADIENT PRESSURE AID (SLEEVE), READY MA
GRADIENT PRESSURE AID (GLOVE), READY MAD
GRADIENT PRESSURE AID (GAUNTLET), READY
CAMISOLE,POST-MASTECTOMY
RESUSCITATION BAG (FOR USE BY PATIENT ON
ADULT SIZED DISPOSABLE INCONTINENCE PROD
ADULT SIZED DISPOSABLE INCONTINENCE PROD
ADULT SIZED DISPOSABLE INCONTINENCE PROD
ADULT SIZED DISPOSABLE INCONTINENCE PROD
PEDIATRIC SIZED DISPOSABLE INCONTINENCE

59.18
90.00
25.00
30.00
18.91
18.00
19.00
31.80
15.84
16.67
16.00
25.00
33.33
25.00
6.01
8.29
8.06

RENTAL
FEE

BR

BR
684.80
66.87
46.50
37.06
198.94
37.80
1.67
3.13
48.60
49.69
0.55
5.00
1105.89
16.50
27.75
54.00
19.13
54.71
67.50
33.82
23.86
22.69
37.49
189.43
0.47
0.51
0.68
0.72
0.30

CODE
T4530
T4533
T4535
T4537
T4539
T4540
T4543
T5001
T5999
T5999
T5999
T5999
T5999
T5999
V5266

DESCRIPTION
PEDIATRIC SIZED DISPOSABLE INCONTINENCE
YOUTH SIZED DISPOSABLE INCONTINENCE PROD
DISPOSABLE LINER/SHIELD/GUARD/PAD/UNDERG
INCONTINENCE PRODUCT, PROTECTIVE UNDERPA
INCONTINENCE PRODUCT, DIAPER/BRIEF, REUS
INCONTINENCE PRODUCT, PROTECTIVE UNDERPA
DISPOSABLE INCONTINENCE PRODUCT, BRIEF/D
POSITIONING SEAT FOR PERSONS WITH SPECIA
SUPPLY,NOT OTHERWISE SPECIFIED
Plastic strips
Basal thermometer
Sterile 6 wood applicator w/cotton tips
Incentive spirometer
Nasal aspirator
BATTERY FOR USE IN HEARING DEVICE

FEE
0.36
0.39
0.28
13.44
6.65
7.19
1.38
609.75
2.81
10.41
2.97
5.88
2.40
0.55

RENTAL
FEE

BR